Sentinel Events & Meetings

Goal - why is this important to us?

Dawn Farm cares about their clients and staff. This gives us an opportunity to reflect on events and make improvements as needed. Also, Dawn Farm has requirements around documentation and analysis for Critical Incidents and Sentinel Events. It is not the purpose of the meeting to assign blame or fault. The primary purposes are learning and support.

Ingredients - what do I need to get started?

An understanding of what a sentinel event is*

A computer-Intranet site-Incident Report link

Sentinel Event -

An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof of clients currently in services with us (RSS, Outpatient, Detox, Outreach, Residential, Housing) OR who have received services with us in the last 30 days.

"Serious injury" specifically includes loss of limb of function. "Or risk thereof" includes any event that would carry a significant chance of a serious adverse outcome.

The following incidents count as sentinel events and will be immediately reported to the Program Coordinator and then documented on an Incident Report form (as outlined by CARF and CMHPSM requirements):

• Medication errors
• Use of seclusion or restraint
• Injury
• Communicable disease or infection
• Aggression or violence (toward staff, visitors or other clients)
• Use or possession of weapons
• Wandering
• Elopement
• Vehicle accidents
• Bio-hazard accidents
• Use or possession of illegal substances
• Abuse
• Neglect
• Suicidal ideation or attempt
• Sexual assault
• Overdose

Timeframe - about how long will this take?

Meetings must be scheduled within 5 business days of the actual event whenever possible.

Meetings are typically 45 minutes.

Contacts - who do I need to let know?

Staff →Your supervisor & Incident Report

Supervisor → Admin Team

Project Manager → Email President, Clinical Director, Coordinators of services received within the last 12 months, & any other staff directly working with clients in the last 12 months.

Steps - what do I do?

1. In the event of any of the above incidents, staff will notify their supervisor immediately and fill out an Incident report.

2. The supervisor will notify the Admin team by email, including the client number and cause of death if known/applicable.

3. The Project Manager will immediately determine if a sentinel event meeting is necessary.

4. If determined as necessary, the Project Manager will convene a Sentinel Event Meeting, inviting any staff and house managers that worked with the client in the last year. The Project Manager will send out a chart including services and dates the clients received services with us in the last year to staff attending the meeting.

Note on meeting attendance- Picking a day & time where everyone is present can be difficult. Keep in mind who is most essential to the meeting. For example, If the client was in housing or d/c within the last 14 days , it is important the the housing coordinator and house manager attend. If the client was receiving RSS services within the last 14 days, the RSS should be present.

5.Project Manager will document the meeting.

6.Sentinel events involving CMHPSM funded clients will be reported to CMHPSM by the Project Manager every six months, per CMHPSM guidelines.

Purpose of Sentinel Event Meeting

1. To review what happened and the client’s service history

2. To identify whether reasonable improvements in programming and policies might prevent future occurrences

3. To review whether there were any errors or direct causes to the incident

4.To provide support for staff who may be experiencing grief, loss, or stress due to the event

5. To identify others (staff, clients, residents) who may need support

Free Grief Counseling Resources (in addition to Dawn Farm staff)

Arbor Hospice-grief support group and workshops

734.662.5999

Stark Funeral Home-grief support group

734.482.4900

St. Joseph Mercy Hospital * Only if the person who died was a patient here.-Bereavement Program

734.327.3224

Lamaze Family Center Miscarriage & Newborn Loss-support group

734.973.1014

CMHPSM Sentinel Event Policy (2014)

Reviewed & updated April 21, 2016, January 2017 updated, reviewed, & meeting preamble created.

CARF Standard 1.H.9.a-f (16), (18)