Section 568.142 - Reporting and Investigating Sentinel Events A hospital shall develop and implement written procedures to identify, report, and investigate sentinel events. The procedures shall include:
(1) a description of the process by which a staff member reports a sentinel event, including a requirement that a sentinel event be reported by a staff member within at least one hour after a staff member becomes aware of the incident; (2) a requirement that, within 24 hours of a sentinel event being reported, the administrator designate a committee to investigate the sentinel event that includes a physician, a Registered Nurse (RN), and any other staff members determined appropriate by the administrator; and (3) a requirement that, within 45 days of the sentinel event being reported, the committee will determine and document: (A) the cause or causes of the sentinel event; (B) whether the cause or causes are random or a pattern of error in the hospital's processes or systems; (C) any improvements to the hospital's processes or systems that may reduce the occurrence of similar incidents in the future; (D) how such improvements will be implemented including a timeline for implementation; (E) the staff members responsible for such implementation; and (F) a method to determine whether the improvements identified were effective in reducing the occurrence of similar incidents.26 Tex. Admin. Code § 568.142
Adopted by Texas Register, Volume 46, Number 21, May 21, 2021, TexReg 3292, eff. 5/27/2021