Instructions (5)
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Nov 24, 2024
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Sentinel Event
Prior to beginning work on this discussion, read through the following webpages and resources
to understand the purpose of documenting sentinel events as well as methods and reporting
requirements:
Sentinel Event Policy and Procedures
The Joint Commission. (2019).
Sentinel event policy and procedures
Links to an external
site.
.
https://www.jointcommission.org/sentinel_event_policy_and_procedures/
Psnet Search
Patient Safety Network (PSNet). (n.d.).
PSNet search
Links to an external site.
. Agency for
Healthcare Research and Quality.
https://psnet.ahrq.gov/search
Sentinel Events
The Joint Commission. (2021, July 1).
Sentinel events
Download Sentinel events
.
Canvas@UAGC.
https://login.uagc.edu
Sentinel Events (SE)
The Joint Commission. (n.d.).
Sentinel eventLinks to an external site.
.
https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/
Topic 6: Understanding and Managing Clinical Risk
World Health Organization. (2021).
Course 6: Understanding and managing clinical
risk
Download Course 6: Understanding and managing clinical risk
.
https://www.who.int/publications/m/item/course-06-understanding-and-managing-clinical-risk
Your initial discussion post must be a minimum of 250 words. All referenced materials must
include citations and references in APA format.
Sentinel events occur in nearly all health care organizations. According to the Maine
Department of Human Services, facilities that are vigilant about identifying and reporting
errors…foster an organizational culture where staff members feel comfortable reporting patient
safety concerns without fear of reprisal. Healthcare facilities that embrace this safety-focused
culture look at adverse events as opportunities to learn and improve. (2018, p. 5)
Sentinel Event Topic:
Suicide events
From a health care provider perspective (e.g., hospital, physician’s practice, long-term care,
hospice, home health, surgery center, etc.), write a brief description of the sentinel event in
your own words.
In addition, address the following:
Identify the sentinel event, who was involved, what occurred, and where it occurred.
Describe the applicable accrediting agency’s requirements for reporting the event (e.g.,
OSHA, ACHA, CMS, CDC, CLIA, The Joint Commission [TJC], AHCA, state agencies).
Discuss the probable cause that may have contributed to the sentinel event (e.g.,
process failure, human error, policy error, systems error, technology failure, etc.).
Create a recommendation that will reduce the risk of future events from occurring.
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