A hospital shall develop and implement written procedures to
identify, report, and investigate sentinel events. The procedures
shall include:
(1) a description of the process by which a staff member
reports a sentinel event, including a requirement that a sentinel
event be reported by a staff member within at least one hour after
a staff member becomes aware of the incident;
(2) a requirement that, within 24 hours of a sentinel
event being reported, the administrator designate a committee to investigate
the sentinel event that includes a physician, a Registered Nurse (RN),
and any other staff members determined appropriate by the administrator;
and
(3) a requirement that, within 45 days of the sentinel
event being reported, the committee will determine and document:
(A) the cause or causes of the sentinel event;
(B) whether the cause or causes are random or a pattern
of error in the hospital's processes or systems;
(C) any improvements to the hospital's processes or
systems that may reduce the occurrence of similar incidents in the
future;
(D) how such improvements will be implemented including
a timeline for implementation;
(E) the staff members responsible for such implementation;
and
(F) a method to determine whether the improvements
identified were effective in reducing the occurrence of similar incidents.
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