Texas Administrative Code
Title 26 - HEALTH AND HUMAN SERVICES
Part 1 - HEALTH AND HUMAN SERVICES COMMISSION
Chapter 568 - STANDARDS OF CARE AND TREATMENT IN PSYCHIATRIC HOSPITALS
Subchapter H - PERFORMANCE IMPROVEMENT
Section 568.142 - Reporting and Investigating Sentinel Events

Universal Citation: 26 TX Admin Code ยง 568.142

Current through Reg. 49, No. 38; September 20, 2024

A hospital shall develop and implement written procedures to identify, report, and investigate sentinel events. The procedures shall include:

(1) a description of the process by which a staff member reports a sentinel event, including a requirement that a sentinel event be reported by a staff member within at least one hour after a staff member becomes aware of the incident;

(2) a requirement that, within 24 hours of a sentinel event being reported, the administrator designate a committee to investigate the sentinel event that includes a physician, a Registered Nurse (RN), and any other staff members determined appropriate by the administrator; and

(3) a requirement that, within 45 days of the sentinel event being reported, the committee will determine and document:

(A) the cause or causes of the sentinel event;

(B) whether the cause or causes are random or a pattern of error in the hospital's processes or systems;

(C) any improvements to the hospital's processes or systems that may reduce the occurrence of similar incidents in the future;

(D) how such improvements will be implemented including a timeline for implementation;

(E) the staff members responsible for such implementation; and

(F) a method to determine whether the improvements identified were effective in reducing the occurrence of similar incidents.

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