Sentinel Event Report Form

Sentinel Event Report Form

Instructions: Baltimore City behavioral health treatment and service providers are asked to complete and submit this form within 48 hours following a sentinel event to the BHSB Compliance & Quality Administrator or Program Lead. For more information please contact Tesha Milton at 410-637-1900 ext. 7844 or .

Definition: A sentinel event is an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events are called “sentinel” because they signal the need for immediate investigation and response. (JCAHO, January 2013) Examples include:

1. Death of a client,
2. Death of a visitor or staff member while at the program site,
3. Sexual assault that occurs in the program,
4. Serious injury to a patient while at the program that requires medical attention,
5. Assault on a client, staff member, or visitor, any battery on a client, staff member, or visitor or any abuse, neglect, or exploitation of a client, staff member, or visitor by another client, program staff or visitor, and
6. External disaster or other emergency situation that affects the continued safe operation of the program.
7. Overdose (lethal and non-lethal)
8. Suicide attempt
9. Medication diversion/dispensing errors (medication missing/stolen from program, spillage during dispensing, dosing errors, etc.)

1. Program Name:

1. Program Director,Phone & Email:

1. Clinical Director,Phone & Email:

1. Location, Date & Time of Event:

1. Brief Description of Event:

1. What persons were involved in event? If persons involved were under 18 years of age, was family/ guardian notified? ☐ Yes ☐ No

1. What is the current status of the affected individuals?

1. Is there any risk to safety of other clients or staff as a result of event?

1. What is the current status of program operations?

1. Was 911 called?☐ Yes ☐ No

1. Was medical attention provided to anyone?☐ Yes ☐ No

1. Was anyone transported to hospital?☐ Yes ☐ No

1. If yes to questions above, please provide brief description:

1. Was police report filed?☐ Yes ☐ No

1. If yes, please provide brief description of arrests, criminal charges, etc.

1. Was there press coverage?☐ Yes ☐ No

1. Next steps/immediate or long-term corrective actions?