Policy Manual sample

MDT Home Health Care Agency, Inc. SENTINEL EVENTS Adverse Events PURPOSE: To promote patient safety by identifying and reducing the risk of sentinel events. To measure, assess and improve MDT Home Health Care Agency, Inc.’s performance in the delivery of patient care, treatment and/or services, maintain a process for identifying, reporting, monitoring, investigating and documenting all adverse events, incidents, accidents, variances, or unusual occurrences. To identify, track, trend, respond to sentinel events that occur while a patient is receiving care, treatment and/or services from MDT Home Health Care Agency, Inc. To implement a proactive process to minimize or prevent the occurrence of sentinel events. To comply with the accreditation standards and any other applicable laws, regulations and standards. POLICY: MDT Home Health Care Agency, Inc. chooses at least one (1) high-risk process annually to monitor, analyze and restructure/redesign, if necessary, to minimize the potential of negatively impacting patient safety. Unexpected events or occurrences involving death or serious physical or psychological injury, or the risk thereof (i.e., sentinel events) are to be reported to the Director of Nursing, Clinical Manager/Administrator/Corporate Compliance Officer immediately upon identification. Any sentinel event requires immediate action to examine, in depth, the event to determine why the incident occurred and to identify interventions with the greatest likelihood of reducing recurrence. DEFINITIONS: Adverse Event: An event or occurrence which results in significant patient injury or impairment, or the risk thereof. An adverse event includes but is not limited to: All confirmed transfusion reactions All serious drug events resulting in a significant condition change in the patient All medication errors, whether or not there is a resultant adverse impact on the patient’s condition Any occurrence having an adverse effect on the patient PROCEDURE: Each and every employee is responsible to report any and all potential or actual sentinel events to their immediate Supervisor. Action to notify the supervisor or after hours’ personnel The report can be by phone, e-mail, or in person, after hour must be contacted our On call services. The Supervisor should notify the Director of Nursing, Clinical Manager/Administrator/Corporate Compliance Officer and complete an Unusual Occurrence Report Form. Time frame for verbal and written notification must be within 6 hours after incident occur. Appropriate documentation and routing of information Home Health Agency Nursing Manual J-66