Sentinel Events and Incidents 624-05-15-50-33

(Revised 10/15/12 ML #3341)

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PI 17-30

 

 

The Risk Management incident report SFN 50508 must be completed by the Regional Supervisor and filed with State Risk Management within 24 hours. The on-line reporting system, www.nd.gov/risk, is used to report both a sentinel event or an incident.

 

Additional information may be attached to an incident report. Any additional information must be filed with State Risk Management and also sent to the DHS Risk Manager and DHS Legal Advisory Unit Director.

 

If you are uncertain whether a situation is a sentinel event or an incident, consultation is available through the Regional Supervisor, CFS or the DHS Risk Manager. A sentinel event will always require an incident report, but every incident reported is NOT a sentinel event.

 

Sentinel Events:

A sentinel event is defined as any unexpected occurrence involving death or serious physical or psychological injury or risk thereof that is not related to the natural course of the individual’s illness or underlying condition. Serious injury specifically includes inappropriate sexual contact. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. They signal the need for immediate investigation and response.

 

An example of a sentinel event would be if a foster youth is seriously injured, (including inappropriate sexual contact), dies unexpectedly, or attempts suicide.

 

Regional Supervisors must report all sentinel events to the Regional Director, Institution Superintendent, or Local Risk Manager immediately. The event also must be reported to the DHS Executive Director, DHS Risk Manager and DHS Legal Advisory Unit Director as soon as possible, but no later than 12 hours after the occurrence. Initial notification may be made by phone, voice mail, or e-mail.

 

Incidents:

An incident is an unplanned occurrence that resulted or could have resulted in injury to people or damage to property, specifically involving the general public and state employees. An incident can also involve issues such as harassment, violence, and discrimination. An incident may be referred to as an accident or near miss.

 

Utilize the Risk Management Fund Incident Report (SFN 50508) for general and employee incidents. The report should be completed by the employee that has the most information or first-hand knowledge about the incident. Incident reports should not be completed by non-state employees. An example of an incident that is not a sentinel event would be if a foster youth runs away.

 

If there are questions regarding this policy, please feel free to contact the CFS Foster Care Administrator or the DHS Risk Manager.