What to Expect During a Sentinel Event Meeting

Preamble

Sentinel event meetings are convened whenever an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof with clients who have been in a Dawn Farm service in the last 30 days.

It is not the purpose of the meeting to assign blame or fault. The primary purposes are learning and support.

More specifically, the purposes of the meetings include:

• To review what happened and the client’s service history
• To identify whether reasonable improvements in programming and policies might prevent future occurrences
• To review whether there were any errors or direct causes to the incident
• To provide support for staff who may be experiencing grief, loss, or stress due to the event
• To identify others (staff, clients, residents) who may need support

Some examples of actions resulting from sentinel event meetings include the transitional housing relapse protocol, keeping naloxone at all Dawn Farm sites and lobbying for 911 Good Samaritan legislation.

This is not just another meeting

In this meeting, we encourage you to talk about your professional interactions and judgements as well as your personal reactions. We encourage you to feel free to participate in this meeting as an addiction professional and as a human being. The following is adapted from Rachel Naomi Remen, a doctor who educates on other doctors on dealing with grief and loss.

As professional helpers, there’s an expectation that we do not grieve the loss of a client or other disappointments.

The expectation that we can be immersed in suffering and loss daily and not be touched by it is as unrealistic as expecting to be able to walk through water without getting wet. This sort of denial is no small matter. The way we deal with loss shapes our capacity to be present to life more than anything else. The way we protect ourselves from loss may be the way in which we distance ourselves from life. We burn out, not because we don't care, but because we don't grieve. We burn out because we have allowed our hearts to become so filled with loss that we have no room left to care.

No one is comfortable with loss. Our first response to loss is try and fix it. When we are in the presence of a loss that cannot be fixed, we feel helpless and uncomfortable and we have a tendency to avoid, either emotionally or physically. Fixing is too small a strategy to deal with loss.

We can’t fix what happened or what is happening for clients, families or our co-workers. But, we can offer the power of our presence, of simply being there and listening and witnessing another person and caring about another person's loss, letting it matter. Letting it matter and listening generously.

Items for discussion

Discussion may include:

• What happened?
• What was this person’s service history?
• How did we learn what happened?
• What were people’s thoughts and feelings when we learned?
• Have people’s thoughts and feelings changed since we learned?
• What can we learn from this event?
• Are there any practices/procedures/policies that should be changed or initiated based on these lessons?
• Who was affected?
• Is there anything that we can/should do for the affected?
• Do affected employees need anything from Dawn Farm?

Closing

• Identify any action items.
• Have a moment of silence.
• Ask if anyone has anything else to say or ask.
• Thank everyone for their time and encourage them to reach out if anything else comes up.