/policies/,/policies/clinical/,/policies/clinical/uw-health-clinical/,/policies/clinical/uw-health-clinical/administrative/,/policies/clinical/uw-health-clinical/administrative/event-reporting-and-grievance/,

/policies/clinical/uw-health-clinical/administrative/event-reporting-and-grievance/132.policy

201705130

page

100

UWHC,UWMF,

Policies,Clinical,UW Health Clinical,Administrative,Event Reporting and Grievance

Reporting Unexpected Events and Determination of Sentinel Event Status (1.3.2)

Reporting Unexpected Events and Determination of Sentinel Event Status (1.3.2) - Policies, Clinical, UW Health Clinical, Administrative, Event Reporting and Grievance

1.3.2


UW HEALTH CLINICAL POLICY 1
Policy Title: Reporting Unexpected Events and Determination of Sentinel Event Status
Policy Number: 1.3.2
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: April 14, 2017

I. PURPOSE

To improve patient care by encouraging and requiring proper reporting and investigation of unexpected
events. To facilitate review by the Risk Management Department, to ensure compliance with requirements
for liability coverage and to address accreditation requirements for the review and analysis of sentinel
events.

II. DEFINITIONS

Patient Safety Net (PSN): PSN is a web-based event reporting system that is available on U-Connect
(Quick Links) and via Health Link.

Root Cause Analysis (RCA) Subcommittee: The UW Health Root Cause Analysis (RCA) Sub Committee
reviews the services UW Health health care clinicians and staff provide to help improve the quality and
safety of health care services. On behalf of the UW Health Leadership and medical staff, the RCA
subcommittee is responsible for chartering RCA teams when adverse events occur, reviewing team findings
with regards to adverse event investigations and reviewing action plans to prevent and/or recover from
future adverse events.

Sentinel event: An unexpected adverse event involving death, major permanent loss of function, sensory,
motor, physiological, or intellectual impairment not present on admission requiring continuing treatment or
life-style changes, or other serious physical injury. Additional events are also considered sentinel events
regardless of outcome. These events are listed in III.B.

III. POLICY ELEMENTS

A. Unexpected occurrences involving death or serious physical or psychological injury (including loss of limb or
function), or risk thereof, shall be reported to the Department of Risk Management so that appropriate
review can be conducted and timely reports can be made to peer review committees, insurance carriers,
and others. When there is a question of whether major loss of function is permanent, applicability of the
policy is not established until either the patient is discharged with continued major permanent loss of
function, or two weeks have elapsed with persistent major loss of function, whichever occurs first.
B. This policy does not require reporting all deaths, loss of function or other serious adverse physical
outcomes. These outcomes need to be reported only when they are unexpected occurrences. Such
outcomes need not be reported when they are related to the natural course of the patient's illness or
underlying condition. Outcomes that are known risks of properly performed treatments are considered
related to the natural course and need not be reported. Examples of "death, major permanent loss of
function, or other serious physical injury" are given in section IV. The following events shall also be reported
regardless of outcome:
i. Suicide of any individual receiving care, treatment or services in a staffed around-the-clock care
setting or within 72 hours of discharge, including from the hospital’s emergency department
ii. Unanticipated death of a full-term infant.
iii. Abduction of any individual receiving care, treatment or services.
iv. Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care
setting (including the ED), leading to death, permanent harm, or even temporary harm to the
patient
v. Discharge of an infant to the wrong family.
vi. Rape, assault (leading to death, permanent harm, or severe temporary harm) or homicide of any
patient receiving care, treatment, and services while on site at the organization.
vii. Rape, assault (leading to death, permanent harm, or severe temporary harm) or homicide of a staff
member, licensed independent practitioner, visitor, or vendor while on site at the organization.
viii. Hemolytic transfusion reaction involving administration of blood or blood products having major
blood group incompatibilities (ABO, Rh, other blood groups).
ix. All events of surgery and nonsurgical invasive procedure on the wrong patient, wrong site, or wrong



UW HEALTH CLINICAL POLICY 2
Policy Title: Reporting Unexpected Events and Determination of Sentinel Event Status
Policy Number: 1.3.2

procedure, regardless of the magnitude of the procedure.
x. Unintended retention of a foreign object in an individual after surgery or other procedure.
xi. Severe neonatal hyperbilirubinemia (bilirubin>30milligrams/deciliter).
xii. Prolonged fluoroscopy with cumulative dose > 1,500 rads to a single field or any delivery of
radiotherapy to the wrong body region or >25% above the planned radiotherapy dose.
C. Any potential liability claim or suit should also be reported to the Department of Risk Management so that a
timely investigation is conducted.

IV. PROCEDURE

A. When an event occurs which must be reported under this policy, one of the following
departments/individuals must be notified in person. The persons should be contacted in the order listed until
one personally receives the notice. If the event occurs during off hours, contact the administrator on call first
via paging at 262-2122. The notice should be given no later than 24 hours after discovery of the event and
generally should be given during the shift when the event is discovered. Other staff and committees that
conduct case review and become aware of such events should report the event when it is not known to have
been previously reported. A Patient Safety Net (PSN) report should also be completed following personal
notification. See UWH administrative policy #4.22, Event Reporting.
i. Risk Management – 261-1327
ii. Legal Department – 261-0025
iii. Senior Vice President/Medical Affairs – 265-0210
iv. Administrator on call, via paging – 262-2122
B. Next working day, anyone notified of an event under A. ii-iv will notify the Risk Management Department.
C. The Legal Department, or designee (e.g., Risk Management) will review the report and coordinate prompt
investigation to determine whether sentinel event review is warranted. Appropriate investigation, reporting
and other action will be conducted at the direction of and for the Chief Legal Officer. Sentinel event
determination will be made at the next event evaluation team meeting, based on the results of the
investigation and a root cause analysis (RCA) team will be charged, if applicable.
D. If sentinel event review is likely indicated or confirmed to be necessary, senior leaders shall be notified as
soon as possible by the Director of Risk Management and Legal Department. A root cause analysis shall be
conducted with oversight by the RCA Subcommittee with staff assistance from the Department of Quality,
Safety & Innovation. The event evaluation team may also recommend peer review of events that are not
deemed to be sentinel events, using root-cause analysis or other methods.
E. The root cause analysis, along with a proposed corrective action plan, shall be completed within 45 business
days of determination of sentinel event status and reported to the RCA subcommittee. The corrective plan
shall be implemented by those specified in the plan. The RCA team facilitator or other designated member
will monitor the actions and recommendations to ensure corrective action plan completion. Completion of
action items are monitored and status updates are provided to the RCA subcommittee. The Quality and
Patient Safety Committee will be informed of the root cause analysis and when applicable,
recommendations for organization-wide performance improvement initiatives are made. The CEO and Vice
President of Quality and Patient Safety will determine the reporting of sentinel events to external agencies
on a case-by-case basis.
F. If the event is not classified as a sentinel event, the event evaluation team may direct an analysis be
completed with staff assistance of the Department of Quality, Safety & Innovation. The analysis will be
completed within 90 days unless a different time period is authorized by leadership. The analysis, along with
a proposed corrective action plan, shall be reported to the RCA Subcommittee. Upon approval of a
corrective plan, the plan shall be implemented by those specified in the plan.

V. EXAMPLES

Examples of death, major permanent loss of function, or other serious physical injury include:

A. Death, paralysis, coma, or major permanent loss of function associated with a medication error.
B. Patient death or major permanent loss of function from assault, homicide or other crime.
C. Death or major permanent loss of function resulting from a fall.
D. Loss of limb.
E. Significant clinical deficits, including but not limited to: brain damage, permanent paralysis including
paraplegia and quadriplegia, and partial or complete loss of sight or hearing, or kidney failure.



UW HEALTH CLINICAL POLICY 3
Policy Title: Reporting Unexpected Events and Determination of Sentinel Event Status
Policy Number: 1.3.2

F. Severe burns, including but not limited to: thermal, chemical, radiological, or electrical.
G. Severe internal injuries, including but not limited to: laceration of an organ, infectious process, and sensory
or reproductive organ injury.
H. Substantial disability, including but not limited to: fractures, amputation, or disfigurement.
I. Other sensory, motor, physiological, or intellectual impairment not present on admission requiring continuing
treatment or life-style changes.
J. Retention of a foreign body such as a sponge during surgery.

VI. COORDINATION

Author: UW Health Director of QSI
Senior Management Sponsor: SVP, Chief Admin Officer
Reviewers: Healthcare Event Evaluation Team (HEET); Director, Risk Management
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: December 19, 2016

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL

Peter Newcomer, MD
Chief Clinical Officer

Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

The Joint Commission, Accreditation Manual for Hospitals, current edition. Assessed at w
ww.jointcommission.org
UWH administrative policy #4.22, Event Reporting

IX. REVIEW DETAILS

Version: Revision
Last Reviewed: April 14, 2017
Next Revision Due: April 2020
Formerly Known as: Hospital Administrative policy #4.40