· Identify the sentinel event, who was involved, what occurred, and where it occurred.
· Describe the applicable accrediting agency’s requirements for reporting the event (e.g., OSHA, ACHA, CMS, CDC, CLIA, The Joint Commission [TJC], AHCA, state agencies).
· Discuss the probable cause that may have contributed to the sentinel event (e.g., process failure, human error, policy error, systems error, technology failure, etc.).
· Create a recommendation that will reduce the risk of future events from occurring.