Definition of Sentinel Events:

A sentinel event refers to a patient safety incident that affects a patient and results in death, permanent injury, or serious harm that requires life-sustaining intervention. An event may also be classified as sentinel even if it does not cause death, permanent damage, or severe temporary harm, provided it indicates a serious issue that demands prompt investigation and response.

 List of Sentinel Events Required to Be Reported:

1.    Abduction of any patient receiving care within a healthcare facility
2.    Discharge of an infant to the wrong family
3.    Discharge of a Minor or Incapacitated Patient to an unauthorized person
4.    Suicide, attempted suicide, or self-harm that results in severe, temporary harm, permanent harm, or death while being cared for in a healthcare setting or within 72 hours of discharge
5.    Staff Suicide, attempted suicide, or self-harm that results in severe, temporary harm, permanent harm, or death.
6.    invasive diagnostic or therapeutic procedures or surgery, on the wrong patient, wrong site or side, wrong implant
7.    Fertilizing wrong sperm to wrong ovum, or implant wrong embryo to wrong mother, or un unexpected damage to embryos, sperm, eggs, or frozen tissue in fertilization and infertility
8.    Administration of incompatible ABO, Non-ABO of blood/ blood products, or transplantation of incompatible organs
9.    Unintended retention of a foreign object in a patient after surgical/invasive procedure
10.    Unexpected death of full-term newborn
11.    Rape cases encountered within the premises/campus of health care
12.    Assault or homicide of any patient receiving care, treatment, and services at the health care facility setting
13.    Assault or homicide of visitor or watcher receiving care, treatment, and services at the health care facility setting
14.    Physical and psychological violence, or homicide of a staff member, or vendor at the health care facility sitting
15.    Fire, flame, or unanticipated smoke, or flashes occurring within a healthcare facility
16.    Unauthorized discharge of the patient (escape) during the period of health care resulting in temporary serious harm, chronic damage or death
17.    Medication error leading to death, permanent, or severe temporary harm
18.    Patient death, permanent, or severe temporary harm associated with intravascular air embolism
19.    Patient death, permanent, or severe temporary harm as a result of medical device breakdown or failure when in use
20.    The unexpected building collapse or malfunctioning structure or overturning of any healthcare facility load bearing part of any lift or lifting equipment when in use or during installation
21.    Transfusing/transplantation of contaminated blood, blood products, organ or tissue or transmission of disease result of using contaminated instrument provided by the health care facility
22.    Death or serious disability associated with failure to manage/identify neonatal hyperbilirubinemia
23.    Delivery of radiotherapy to the wrong body region or dose exceeds more than 25% of the total planned radiotherapy dose
24.    Patient death, permanent harm, or severe temporary harm as a result of patient fall
25.    Patient death, permanent harm, or severe temporary harm associated with wrong administration/connection of medical gas
26.    System failure leading to service interruption and total evacuation outside health care facility
27.    Unexpected death
28.    Unexpected loss of a limb or function
29.    Maternal death, permanent harm, or severe, temporary harm
30.    MRI damage or patient or staff sever temporary harm or death associated with introduction of metallic object
31.    Loss or damage to specimen or tissue biopsy after invasive procedure

CBAHI Policy on Sentinel Events:

• Disclosure and Transparency: Patients and their families have the right to receive honest and clear communication in the event of a sentinel event.

 • Just Culture: Individuals are not held accountable for errors resulting from system failures; instead, the focus is placed on improving and correcting the system.

 • Non-Punitive Environment: No disciplinary action shall be taken against any staff member who reports a sentinel event.

Reporting and Follow-up Mechanism:

All healthcare facilities accredited by CBAHI are required to:

•  Report the event within 5 working days from the date of occurrence through the designated sentinel event electronic platform for hospitals

•  For primary healthcare centers, medical complexes, and other programs: the sentinel event should be reported via the designated email: SERF@CBAHI.GOV.SA.

•  Conduct a Root Cause Analysis (RCA) and CAP to mitigate risks within a maximum of 30 working days.

CBAHI may follow up on sentinel events through progress reports or focused visits (announced or unannounced).

Objectives:

•  Transform errors and adverse events into opportunities for learning and continuous improvement.

•Protect patients from unintended harm.

 • Strengthen public trust in the healthcare system through transparency and commitment to quality.

 For inquiries and communication regarding sentinel events:

SERF@CBAHI.GOV.SA