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

(Revised 5/1/21 ML #3616)

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A foster care case manager witness to or having knowledge of an incident or sentinel event must immediately report to their agency supervisor, director, and CFS Field Service Specialist. If the foster care case manager is uncertain whether a situation is a sentinel event or an incident, consultation is available through the CFS Field Service Specialist, CFS Foster Care Administrator or the DHS Risk Manager.

 

A sentinel event will always require an incident report, but every incident reported is NOT a sentinel event.

 

Children and Family Services Field Service Specialists must enter all incidents and sentinel events into the ND OMB Risk Management incident reporting system https://omb.nd.gov/incidentreporting within 24 hours.

 

A. Sentinel Event

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. The phrase “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called sentinel because they signal the need for immediate investigation and response. Examples of a sentinel event that could occur during the course of foster care placement is if a child is seriously injured (including inappropriate sexual contact), there is an unexpected death or attempted suicide.

 

Initial notification must be made by phone, voicemail, or e-mail as soon as possible, but no later than twelve (12) hours after the occurrence. If the Field Services Specialist feels other relevant parties (not indicated below) should be notified, they can be added to the email sent summarizing the sentinel event.

 

For sentinel events notification must be sent to:

1. CFS Director,
2. CFS Foster Care Administrator,
3. DHS Risk Manager, and
4. DHS Legal Advisory Unit Director.

Field Service Specialists will document this online as a “medical case incident report for clients” within 24 hours of being notified of the sentinel event. Any subsequent information, not to include a SFN 960 unless requested by authorized staff, must be attached to the initial incident report with State Risk Management OMB and also sent to the DHS Risk Manager.

 

B. Incidents

An incident is an unplanned occurrence that resulted or could have resulted in injury to people or damage to property, specifically involving public or 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. An example of an incident that is not a sentinel event would be if a foster child runs away, is involved in a non-life-threatening vehicle accident, or the child sustains a minor injury.

 

Initial notification must be made by phone, voicemail, or e-mail as soon as possible, but no later than twelve (12) hours after the occurrence. If the Field Services Specialist feels other relevant parties (not indicated below) should be notified, they can be added to the email sent summarizing the incident.

 

For incident reports notification must be sent to:

1. CFS Foster Care Administrator,

2. DHS Risk Manager.

 

Field Service Specialists will document this online as a “medical case incident report for clients” within 24 hours of being notified of the incident.