Describe the applicable accrediting agencys 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. 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 PSNet Search Facts About the Sentinel Events Policy Sentinel Events (SE) Topic 6: Understanding and Managing Clinical R 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 errorsfoster 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.
