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.

Source Note: The provisions of this §568.142 adopted to be effective May 27, 2021, 46 TexReg 3276