House Staff Manual - Winthrop University Hospital

Sentinel events are considered unexpected occurrences involving the death or serious physical orpsychological injury to a patient or visitor, or the risk thereof. Serious injury specifically includes loss oflimb or function. The phrase “or the risk thereof” includes any process variation for which a recurrencewould carry a significant chance of serious adverse outcome. Such events are called “sentinel” becausethey sound a signal for the need for immediate investigation and response.Sentinel events include, but are not limited to, the following: suicide; infant abduction or discharge towrong family; rape (including assault, homicide, or other crime resulting in patient death or majorpermanent loss of function); hemolytic transfusion reaction; surgery on wrong patient, wrong body part,or wrong side of body; intrapartum maternal death (related to birth process); any perinatal death unrelatedto a congenital condition in an infant having a birth weight of greater than, or equal to, 1000 grams.In the event you become aware of an actual or potential sentinel event, you must immediately notify RiskManagement, or the Administrator on call during nights, weekends and holidays. You must also notify thepatient’s attending physician and faculty responsible for the clinical area involving the patient. Uponnotification of a possible or actual sentinel event, a root cause analysis team will be convened and facts willbe reviewed to determine whether the situation is in fact a sentinel event. All cases referred through theincident reporting process are addressed through the quality improvement program to identify process andsystem weaknesses and improve patient safety (see Policy/Procedure APPM I-10-1).81. SEXUAL HARASSMENTThe following is Winthrop-University Hospital's policy on sexual harassment, which is a violation of TitleVII of the Civil Rights Act.Sexual harassment is a form of misconduct which undermines respect for individual dignity. By definition,unwelcome sexual advances, requests for sexual favors and other verbal or physical conduct of a sexualnature constitute sexual harassment when:Submission to such conduct is made either explicitly or implicitly a term or condition of an individual'semployment;Submission to or rejection of such conduct by an individual is used as the basis of employmentdecisions affecting such individual;Such conduct has the purpose or effect of substantially interfering with an individual's workperformance or creating an intimidating, hostile or offensive working environment (EPOCH).Individuals who believe they have been sexually harassed may obtain redress through the establishedinformal and formal procedures of the institution. Complaints about sexual harassment will be respondedto promptly and equitably. The right to confidentiality of employees/residents of Winthrop-UniversityHospital will be respected in both informal and formal procedures, insofar as possible. This policyexplicitly prohibits retaliation against individuals for bringing complaints of sexual harassment. Violationof this policy may subject the violator to appropriate disciplinary action, up to and including termination ofemployment.If you believe that you are experiencing sexual harassment in any form, contact the Hospital's HumanResources Department (ext. 2353). An Employee Relations representative will help you to resolve theproblem in a prompt and confidential manner.82. UTILIZATION MANAGEMENTState and Federal law require every hospital to carry out an approved "Utilization Management Plan". Theutilization plan is designed to assure effective utilization of hospital services and to maintain quality carethrough the analysis, review and evaluation of clinical practices within the Hospital.Rev. 1/08