![]() When an event occurs, investigate per your policy/procedure. ![]() Log and track sentinel events within your Performance/Quality Improvement Program.It should also state who within the organization is responsible for the documentation and follow up. The policy should not only define sentinel events, but also speak to how the events and the organization’s follow up are documented. Have a policy/procedure that defines sentinel events within your organization.So, what is expected of an organization that has a sentinel event? According to the standard QM 2, these are the requirements: The supplier should consider possible links between the items and services furnished and the adverse event. The investigation includes all necessary information, pertinent conclusions about what happened, and whether changes in systems or processes are needed. For other occurrences, the supplier shall investigate within 72 hours after being made aware of the incident, infection or injury. ![]() The investigation should be initiated within 24 hours after a supplier becomes aware of an injury or incident, or infection resulting in a client’s hospitalization or death. The organization’s performance improvement program meets all relative payer requirements regarding monitoring, reporting and follow-up. All sentinel/adverse events are reported to the proper regulating body(ies), the organization’s leadership, and accrediting body. The organization defines, monitors, and provides the appropriate follow-up for all sentinel/adverse events pertaining to its product line(s) or delivery of service. The standard is Quality Management (QM) 2. HQAA has a standard that addresses the responsibilities a DME bear in relation to sentinel events that occur within their organization. ![]() A person dying because a ventilator stopped working IS. A person dying on a ventilator is not a sentinel event. But sentinel events ARE extreme! Notice that they are caused by the equipment or the staff person. These seem like-and are, extreme examples. DME personnel/employees assisting with patient transfer cause or allow the patient to fall, breaking a hip or leg.Poorly fit orthotic device or diabetic shoe causing sores that lead to infection which escalates to “serious injury” or amputation.DME personnel/employees assaulting or abusing customer/patients in the course of their care.Oxygen fires resulting from patients smoking or coming in contact with a fire source such as a gas stove, fireplace, or candle.Ventilator equipment malfunction/failure resulting in death or serious injury.Well documented examples of DME sentinel events include: In the home care / DME setting, sentinel events are relatively uncommon occurrences, but they do happen from time to time. They can also include giving a wrong medication if it results in death or serious injury, rape or assault on a patient, and burns from oxygen fires. In hospitals, these events include the rather ominous sounding ‘wrong-site surgery,’ including terrible scenarios such as amputation of the wrong limb. Healthcare facilities such as hospitals and skilled nursing facilities use the terminology and durable medical equipment providers have adopted the same terminology perhaps in an effort to speak the same language with payers, referral sources, and of course, the regulatory bodies and accrediting agencies. In medical industries, sentinel events are defined as “ unanticipated events or occurrences resulting in death or serious injury to a patient not related to the patient’s illness, but related to the medical equipment, supplies, or care being provided." For the purposes of our discussion here, “adverse events” and “sentinel events” are one in the same. Sentinel – verb –" To watch over, stand guard, or protect some place, person, or area” Sentinel – noun – “ A soldier or guard whose job is to stand and keep watch ”
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