TAILIEUCHUNG - Sentinel Event Data Event Type by Year 1995-2012

The lead agency must also coordinate with other agencies and review security plans for infrastructure and utilities that could threaten event security (local water supply, water treatment facilities, electricity supply, communications grid, sewer system, computer systems, etc.). At some special events, manhole covers have been welded shut near the event venues. Often, newspaper dispensers and public trash cans are removed before an event (they can be hiding places for bombs and can be used as missiles to harm law enforcement or destroy property). When such measures. | Sentinel Event Data Event Type by Year 1995-2012 The Joint Commission Copyright The Joint Commission Sentinel Event http Sentinel Event Policy and Procedures F A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase or risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. F Such events are called sentinel because they signal the need for immediate investigation and response. F The term sentinel event and medical error are not synonymous not all sentinel events occur because of an error and not all error result in sentinel events. Copyright The Joint Commission The Joint Commission Office of Quality Monitoring - 2 Reviewable Sentinel Events F http Sentinel Event Policy and Procedures F The event has resulted in an unanticipated death or major permanent loss of function not related to the natural course of the patient s illness or underlying condition. OR F The event is one of the following and does not require an outcome of death or major permanent loss of function Suicide of any patient receiving care treatment and services in a staffed around-the-clock care setting or within 72 hours of discharge. Unanticipated death of a full-term infant Abduction of any patient receiving care treatment and services Discharge of an infant to the wrong family Rape Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities Surgical and nonsurgical invasive procedures on the wrong patient wrong site or wrong procedure Unintended retention of a foreign object in a patient after surgery or other procedure Severe neonatal Hyperbilirubinemia bilirubin 30 miligrams deciliter Prolonged fluoroscopy with cumulative dose 1500 rads to a single field or any .

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