![]() If a patient has died or experienced serious harm that was likely related to the care provided, the health service may be required to notify this adverse event to SCV as a Sentinel Event. Experienced staff then look at what happened, to try and understand what occurred and why. ![]() When patients have been harmed during their health care, health services record these events in their incident management system. How do health services report when things go wrong? This page offers information on the role of Safer Care Victoria (SCV) and the actions health services take when things have gone seriously wrong with patient care. One of the most powerful tools we have to prevent harm from happening again is to learn from it when it does occur. When something does go wrong, it is important for the health service to understand what occurred, how it happened, and to make recommendations to reduce the likelihood of it happening again. Sometimes things go wrong in healthcare, which can result in a patient being harmed. The most current version of the Sentinel Event Policy can be found in the SE chapter in the E-dition or Comprehensive Accreditation Manual.Information for patients, families and carers Clarified content to determine whether a patient safety incident meets criteria for sentinel event review.Reorganized content to flow in a more logical order.Clarified guidance on how to complete a comprehensive systematic analysis and development of an action plan to align with current Joint Commission requirements.Removed redundant verbiage and duplicative content.The final substantive revisions clarify the expectations for healthcare organizations’ collaboration with OQPS, according to the release, which include the following: Permanent harm: An event or condition that reaches the individual, resulting in any level of harm that permanently alters and/or affects an individual’s baseline.Severe harm: An event or condition that reaches the individual, resulting in life-threatening bodily injury, including pain or disfigurement, that interferes with or results in loss of functional ability or quality of life that requires continuous physiological monitoring or a surgery, invasive procedure, or treatment to resolve the condition.Sentinel event: A patient safety event (not primarily related to the natural course of the illness or underlying condition) that reaches a and results in death, severe harm (regardless of duration of harm), or permanent harm (regardless of severity of harm). ![]() OQPS revised the definition to clarify the differences between severe harm, which may or may not be permanent, and permanent harm, regardless of severity. Starting January 1, 2022, the new revisions to the Sentinel Event Policy will apply to all Joint Commission accreditation and certification programs, except for the Health Care Staffing Services and Integrated Care certification programs, according to the release. The revisions clarify expectations regarding a healthcare organization’s partnership and collaboration with OQPS and include editorial revisions to improve the flow of the chapter. The Joint Commission’s Office of Quality and Patient Safety (OQPS) revised its definition of a sentinel event and clarified some of the event-specific examples in the Sentinel Event Policy, according to a July 21 release. NAMES IN THE NEWS Joint Commission Revises Sentinel Event Definition, Policy
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