SENTINEL EVENT POLICY

Policy and Procedure

 Policy and Procedure – SENTINEL EVENT
1- Purpose:
1.1 This Policy defines the process for identifying and reporting a sentinel event to Dubai

Health Authority – Regulatory (DHAR), and to minimize reoccurrence when sentinel events

occur in any Healthcare Operator within DHA.

2- Applicable To:

2.1 This policy is applicable to all Dubai Health Authority (DHA) Licensed Healthcare Operators

and Healthcare Professionals who experience serious patient incidents, including those that

result in an unanticipated death or major permanent loss of limb or function, not related to

the natural course of the patient's illness or underlying condition.

3- Policy & Responsibility:

3.1 All Healthcare Operators in DHA are required to report Sentinel Events to the Quality
Improvement Department within twenty four (24) hours of the event occurring in accordance to
the procedures described in this policy.
3.2 This policy is established to:
3.2.1 Have a positive impact in improving patient care, treatment and services, and preventing
sentinel events.
3.2.2 Focus the attention of an organization that has experienced a sentinel event on
understanding the causes that underlie the event, and on changing the organization’s systems and
processes to reduce the probability of such an event in the future.
3.2.3 Increase general knowledge about sentinel events, their causes and strategies for
prevention.
3.2.4 Provide a structured and process-focused framework with which to approach sentinel
events analysis.
3.3 The Healthcare Operator is responsible for reporting the event to the Quality Improvement
Department, and implement any recommendations provided by the Quality Council.
3.4 The Quality Improvement Department is responsible to ensure that sentinel events are reported,
conduct an on-site visit following a sentinel event, and communicate the incident to the Quality
Council.
 Policy and Procedure – SENTINEL EVENT
3.5
prevent or minimize reoccurrence of a sentinel event.
3.6

recommendations are implemented within the specified time frame.

4- Procedure/Steps: (as applicable)

PROCEDURE SEQUENCE
4.1 In the occurrence of a sentinel event, the Healthcare Operator is
required to complete the “DHAR Sentinel Event Reporting Form”.
4.2 The Healthcare Operator is required to submit the signed “DHAR
Sentinel Event Reporting Form” to the Quality Improvement
Department within twenty four (24) hours of the occurrence.
4.3 The Quality Improvement Department reviews the Healthcare
Operator’s sentinel event reporting form and determines whether
the DHAR Sentinel Event Policy applies to the specific case (the
incident meets the definition of a sentinel event).
4.4 In the event that the incident does not meet the DHAR’s definition
of a sentinel event, the Quality Improvement Department
communicates this decision to the Healthcare Operator, and the
incident must be managed according to the Healthcare Operator
internal incident reporting and management process.
4.5 In the event that the incident does meet the DHAR’s definition of a
sentinel event, the Quality Improvement Department makes an on-
site visit to the Healthcare Operator facility, provides
recommendations for immediate preventative action if required, and
generates a summary report of the event.
4.6 The Healthcare Operator commences a thorough review of the
incident to determine why and how the sentinel event occurred, and
develops an action plan to minimize reoccurrence in the future.
4.7 The Quality Improvement Department communicates the event to
the Director of QID, who then communicates to the CEO of DHAR.
4.8 The Quality Improvement Department reports the sentinel event to
the Quality Council for discussion and review.
 Policy and Procedure – SENTINEL EVENT
4.9 The Quality Council may provide recommendations for action and
timeframes to Quality Improvement Department if required.
4.10 The Quality Improvement Department actions Quality Council
recommendations as appropriate.
4.11 The Quality Improvement Department conducts a follow-up on-site
visit to the Healthcare Operator facility after forty five (45) days to
ensure that a thorough and credible review has been completed and
an action plan has been developed.
4.12 The Quality Improvement Department conducts a follow-up on-site
visit to the Healthcare Operator facility after six (6) months to
ensure that the sentinel event process is completed.

5- Definitions & Abbreviations:

5.1 Action Plan: identifies the strategies that the organization intends to implement in order to
reduce the risk of similar events occurring in the future. The plan should address responsibility
for implementation, oversight, pilot testing as appropriate, time lines, and strategies for
measuring the effectiveness of the actions.
5.2 DHA: Dubai Health Authority.
5.3 DHCR: Dubai Healthcare City Authority Regulatory is the regulatory arm of Dubai Health
Authority. An independent licensing and regulatory authority for all healthcare providers,
medical, educational and other business operating within DHA.
5.4 Healthcare Operator (HCO): an all-inclusive term meaning a hospital, clinic, laboratory,
pharmacy or other entity providing healthcare, engaging in one or more clinical activities.
5.5 Quality Council (QC): An external body that has oversight responsibilities relating to all patient
quality and safety matters in DHA.
5.6 Quality Improvement Department (QID): is the operational arm of the DHAR. The Quality
Improvement Department has the day-to-day responsibility for quality oversight and patient
safety in DHA; implement quality oversight processes, policies and procedures and ensures that
all the outpatient clinics within DHA comply with Dubai Outpatient Quality Standards.
5.7 Root Cause Analysis (RCA): A process for identifying the basic or causal factors that underlies
variation in performance, including the occurrence or possible occurrence of a sentinel event. A
root cause analysis focuses primarily on systems and processes, not on individual performance.
 Policy and Procedure – SENTINEL EVENT
5.8 Sentinel Event: A sentinel event is an unanticipated occurrence involving death or
serious physical or psychological injury. Serious physical injury specifically
includes loss of limb or function. Such events are called sentinel because they
signal the need for immediate investigation and response.

6- Appendices:

6.1 DHAR Sentinel Event Reporting Form

6.2 Sentinel Event Reporting Process Flow Chart

7- Reference:
7.1 Joint Commission International Accreditation Standards for Ambulatory Care, 4th Edition
(Effective 1 July 2019)
7.2 Root Cause Analysis in Health Care. Tools and Techniques. Joint Commission on Accreditation of
Healthcare Organizations, Third Edition, 2005.
7.3 What Every Health Care Organization Should Know About Sentinel Events. Joint Commission on
Accreditation of Healthcare Organizations, Third Edition, 2005.
7.4 DHCA Governing Regulation No. 1 of 2013.
 Policy and Procedure – SENTINEL EVENT
Appendix 1
DHA Outpatient Clinic Sentinel Event Reporting Form

Healthcare Operator (HCO) ID Number: ____________________________________

Healthcare Operator (HCO) Name: ____________________________________

Date of Incident (dd/mm/yyyy): ____________________________________

Event Type

☐ An unanticipated death that is unrelated to the natural course of the patient’s illness or underlying
condition (for example, death from a postoperative infection or a health care–associated infection)

☐ Death of a full-term infant

☐ Major permanent loss of function unrelated to the patient’s natural course of illness or underlying condition

☐ Wrong-site, wrong-procedure, wrong-patient surgery, wrong side of the body, or wrong organ

☐ Transmission of a chronic or fatal disease or illness as a result of infusing blood or blood products or
transplanting contaminated organs or tissues

☐ Haemolytic transfusion reaction involving major blood group incompatibilities

☐ Infant abduction or an infant sent home with the wrong parents

☐ Rape, workplace violence such as assault (leading to death or permanent loss of function), or homicide
(Wilful killing) of a patient, staff member, practitioner, medical student, trainee, visitor, or vendor while on
organization property

☐ Medication error resulting in patient death, paralysis, coma, or other major permanent loss of function

☐ Anaesthesia-related event resulting in patient death, paralysis, coma, or other major permanent loss of function

☐ Suicide / Suicide of a patient in a setting where the patient is housed around-the-clock, or suicide
following elopement (unauthorized departure) from such a setting

☐ Patient fall that results in patient death, paralysis, coma or other major permanent loss of function as a direct
result of the injuries sustained in the fall
 Policy and Procedure – SENTINEL EVENT

☐ Infection-related event resulting in patient death, paralysis, coma, or other major permanent loss of
function

☐ Delay in treatment resulting in patient death, paralysis, coma, or other major permanent loss of function

☐ Use of restraints resulting in patient death, paralysis, coma, major permanent loss of function, or injury

☐ Medical equipment / ventilator-related malfunction or misuse resulting in patient death, paralysis, coma,
or other major permanent loss of function

☐ Op/post-op complication resulting in patient death, paralysis, coma, or other major permanent loss of
function

☐ Utility systems (electricity, water, gas) related event resulting in patient death, paralysis, coma, or other
major permanent loss of function

☐ Other event resulting in unanticipated patient death, paralysis, coma, or other major permanent loss of
function (unrelated to the natural course of the patient’s illness or underlying condition)

Summary of event: (Please describe the event. Do not include the name(s) of staff, patient(s), or other individual(s)
involved in the event)

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 Policy and Procedure – SENTINEL EVENT

HCO Quality and Patient Safety Contact

Person Name:

E-mail Address:

Phone No: Fax No:

Date
Signature (dd/mm/yyyy):

Please deliver this completed, signed DHCC Sentinel Event Reporting Form to the Quality Improvement Department

(QID) at Dubai Healthcare City Authority Regulatory (DHCR) within 24 hours of the event occurrence.

For all correspondence, please use the following information:

Quality Improvement Department DHCR

Ibn Sina Building 27 - Ground Floor, Building C
Dubai Healthcare City
Telephone Number: 04 3838300
Email: QID@dhcr.gov.ae
 Policy and Procedure – SENTINEL EVENT
Appendix 2
Start
SENTINEL EVENT FLOW CHART
Sentinel
HCO completes Sentinel
Event
Event Reporting Form
Occurs

QID reviews the sentinel event reporting form

HCO submit to QID with
and determines if it meets the definition of
in 24 hours of Event
sentinel event

QID Communicates to facility that this

incident doesn’t meet the definition of
Does it meet the
sentinel event and must be managed NO
definition of Sentinel
according to HCO internal incident
event?
reporting process

YES
HCO commences thorough review of
the incident to why and how the QID makes onsite visit to HCO facility, provides recommendations
sentinel event occurred and develops for immediate preventive actions if required and generate a
the action to minimize the summary report of the event
reoccurrence in future
QID communicates event to the Department Director who then
communicates to CEO of DHCR

QID reports the event to QC for discussion and review

QC may provide recommendations for action and timeframes to

QID if required

QID actions QC recommendations as appropriate

Abbreviations:
HCO: Healthcare Operator
QID: Quality Improvement
Department QID conducts a follow-up onsite visit to HCO facility after 45 days
QC: Quality Council of the event to ensure thorough review completed and action plan
developed

QID conducts follow-up onsite visit to HCO facility after 6 months

of the event to ensure sentinel event action process is completed

Stop