BOP Program Statement 6013.01 § 9

defined as an unexpected occurrence involving death, serious

physical injury (loss of limb or function), psychological injury,

or risk thereof, that are associated with the health care

provided to a patient in a Bureau institution.

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The HSA will establish a system of review for any suspected

sentinel event. The system will include a review of the event

and completion of a Root Cause Analysis of Suspect Sentinel Event

(Attachment C) within 45 days of its occurrence. The Root Cause

Analysis is a report that focuses on process and system failures

that may have contributed to the sentinel event.

! This review is a means to evaluate health care delivery by

identifying its significant strengths and weaknesses.

Action steps, based upon the review, will promote and expand

strengths and correct deficiencies. The Root Cause Analysis will

be forwarded to the Medical Director through the appropriate

Regional Director’s office.

This report will contain the following:

! Patient name and register number;

! Description of the event or adverse outcome;

! What processes were involved? If there was a process

failure, why;

! What human factors were relevant to the outcome;

! Did equipment performance effect the outcome;

! Where any other environmental factors relevant to the

outcome? If so, why;

! Did any other factors influence the outcome;

! Identify any risk points and potential contribution to this

event;

! Determine what potential improvements would tend to decrease

the likelihood of such events in the future;

! Provide details of plan to address identified opportunities

for improvement;

! When and who will implement improvements; and

! How will effectiveness of improvements be evaluated.

a. Reportable Sentinel Events. Examples of sentinel events

include:

(1) Suicide and/or homicide of a patient in a setting where

the patient receives around-the-clock supervision

(suicide watch or medical observation patients in non-MRC, inpatients in MRC, or the death of an inmate in

correctional, behavioral health or medical restraints,

in any setting);

(2) Surgery on the wrong body part or patient;

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(3) Any patient death, paralysis, coma, or other major loss

of function associated with a medication error, or

other medical care delivery error; or

(4) A fall, or other accident involving a patient that

results in death or major permanent loss of function as

a direct result of injuries sustained in the fall.

Patients in this category are usually in-patients or

can be outpatients with identified disorders such as

epilepsy, neurologic disorders, etc.

b. Non-Reportable Sentinel Events. The following are examples

of events that present risks that should be evaluated and are

considered non-reportable as sentinel events:

(1) Any sentinel event not related to the provision of

patient care;

(2) Medication errors that do not result in death or major

loss of function;

(3) Suicides other than in around-the-clock supervision

settings (general population);

(4) Suicide attempts;

(5) A death that is attributed to the natural course of a

patient’s illness or underlying condition that has been

under treatment.

Only the Medical Director has the authority to determine

whether JCAHO will be notified that a sentinel event has occurred

in any Bureau institution.

Institutions will only report a sentinel event to the Medical

Director.

Institutions should also consider completing the Root Cause

Analysis for incidents that are considered to be a near miss. A

near miss is defined as a process variation which does not affect

the outcome, but for which a recurrence carries a significant

chance of a serious adverse outcome.

c. Focus Review. Should the Medical Director determine that

the Sentinel Event warrants further review, an external focus

review may be authorized.

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! Refer to PS Credentialing/Privileging/Practice

Agreements of Health Care Providers Section 9, 3., a-h.