2.1
Notification and Reporting System.A health care facility must have a
Sentinel Event Notification and Reporting System as part of its facility-wide,
integrated patient safety program for all departments, programs, and services
within the facility that includes but is not limited to:
2.1.1
Discovery System. Each
health care facility shall have policies and procedures for identifying a
sentinel event (Section 1.22). The written policies and procedures must include
but not limited to the following:
2.1.1.1
Copy of the current Sentinel Events Reporting law, 22 M.R.S.A. Chapter
1684.
2.1.1.2 Copy of the current
Rules Governing the Reporting of Sentinel Events, 10-144
C.M.R. Ch. 114.
2.1.1.3 Procedures
for preservation of evidence, including but not limited to the following:
2.1.1.3.1 Procedure for sequestering
equipment involved in the event.
2.1.1.3.2 Procedure for sequestering other
evidence including but not limited to medication vials and intravenous (IV)
administration bags.
2.1.1.3.3
Procedure for identifying clinical indications for requesting an
autopsy.
2.1.1.4
Procedure for periodically reviewing a sample of death logs, transfer logs,
patient complaints, patient records submitted for case review, resuscitation
reviews and other records as a quality assurance mechanism to assure that cases
are being identified and reported.
2.1.1.5 Procedure for communicating the
definition of a sentinel event throughout the organization.
2.1.2
Notification Policy.
Facility sentinel event notification policies and procedures shall include but
are not limited to the following:
2.1.2.1
Facility procedure for notifying the SET.
2.1.2.2 Facility procedure that identifies
the person responsible in the facility for the notification of the SET and, in
the absence of that person, the identification of the alternate person
responsible for the notification of the SET.
2.1.3
Investigation and Reporting
Policies. Facility investigation and reporting policies and procedures
including but not limited to the following:
2.1.3.1 Facility procedure for conducting a
RCA.
2.1.3.2 Facility procedure
that ensures corrective actions are implemented and evaluated for
effectiveness.
2.2
Staff Education. Each
health care facility shall include in new employee orientation and provide to
all individuals with privileges:
2.2.1 The
facility's Sentinel Event Notification and Reporting System policies and
procedures.
2.2.2 Information
regarding the voluntary reporting of near miss events, and the standardized
procedures for notification and reporting sentinel events.
2.2.3 Facility internal processes for
notifying leadership.
2.2.4
Facility responsibility to implement action plans.
2.2.5 Facility responsibility to annually
attest that all sentinel events were reported to the SET.
2.3
Cooperation. A healthcare
facility that has filed a notification or a report of the occurrence of a
sentinel event, pursuant to these rules, must cooperate with the division as
necessary for the division to fulfill its duties described in 22 M.R.S.A.
§8754.
2.4
Annual
Attestation. By January 30th of each year, on
a department-approved form, each healthcare facility must send the SET a
written attestation that contains an affirmative statement that it reported all
sentinel events that occurred in the prior calendar year.
