Date
of Last Review 6/5/07
SME: Director Of Performance Improvement
UT-Harris County Psychiatric Center is committed to improving the quality of
patient care. The occurrence of a sentinel or high risk event identifies an
opportunity for improvement.
A quality improvement/peer review process is used to assess the root cause of the event and opportunities for improvement.
Sentinel event alerts published by JCAHO are used to assist in formulating action plans and preventive measures.
The following are definitions of sentinel and high risk events:
 | Sentinel event - is an unexpected occurrence involving death or serious physical or psychological injury |
| High risk event - Includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome, including delay of diagnosis or treatment |
The following describes criteria for identifying sentinel events applicable to UTHCPC:
| Any unexpected death that is not the result of the patient's underlying condition |
| Impairment (major permanent loss of bodily function that is not the result of the patient's underlying condition) |
| Rape (Unconsented sexual contact involving a patient and another patient, staff member, or unknown perpetrator being treated or on the premises of the health care organization) |
| Assault, homicide, or other crime resulting in patient death or major permanent loss of function |
| Suicide of any individual receiving care, treatment or services in a staffed round-the-clock setting or within 72 hours of discaharge |
| Any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error |
| Any elopement, i.e. unauthorized departure, of a patient from an around-the-clock care setting resulting in a temporally related death (suicide or homicide) or major permanent loss of function. |
| A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall |
|
Abduction of any individual receiving care, treatment or services |
The following describes criteria for identifying high risk events:
| Code blue |
| Medication error resulting in transfer |
| Adverse reaction to medication resulting in medical transfer |
| Suicidal gesture (i.e. completed behaviors that indicate intent to harm but not kill self such as superficial cuts, etc.) while on one-to-one |
| Patient-to-patient injury resulting in discharge to a medical facility |
| Elopement of a unit-restricted patient |
| Suicide attempt by hanging, asphyxiation, deep laceration, or self-administered overdose |
| Inappropriate use of restraint or seclusion (confirmed by Patient Relations) |
| Falls resulting in discharge to a medical facility |
When a sentinel or high risk event occurs it is reported as follows:
Who |
Action | ||||||||
Staff |
| ||||||||
Manager/Nursing Supervisor |
|
The Administrator calls a meeting of the Sentinel and High Risk Event Committee who investigates events using the following models:
| JCAHO Root Cause Analysis |
| Process Improvement |
See Sentinel or High Risk Events and Root Cause Analysis
Patient Care Variance Reporting Process
Administrative Alert - After Hours/Weekends
Occurrence Reporting Process
Patient Safety Plan
The Joint Commission : Improving Organization Performance , Sentinel Events, Center for Medicare Medicaid Services
If you have questions regarding the content of this site please contact the Policy and Procedure Committee. If you experience any technical problems please contact the MIS Department.
