CAMHD 72-HOUR SENTINEL EVENT REPORT

Child & Adolescent Mental Health Division

State of Hawaii Department of Health

72-HOUR SENTINEL EVENT REPORT

Under CAMHD guidelines, a sentinel event is an occurrence involving serious physical and/or psychological harm or the risk thereof. A separate form is required for each singular event within 72 hours of the event occurrence. A 24-hour verbal report is also required to the case Care Coordinator as well as to the CAMHD Sentinel Events Specialist at 733-9356.

Fax to: Sentinel Events Specialist at 733-9357 and fax to FGC Care Coordinator at the appropriate Family Guidance Center fax number. Pages 1 and 2 to be completed by staff witnesses involved.

Agency: ______Program Name:______Provider ID#:______

Street Address (residential facilities only): ______Phone:______

Island:______Reported By: ______Date Reported:______

Level of Service (check one): Hospital-Based Residential  Intensive In-Home

 Multi-Systemic Therapy  Therapeutic Foster Home

 Community Based Residential  Therapeutic Group Home

 Community Based Residential-High Risk  Crisis Residential

 Other:______

Care Coordinator:______Family GuidanceCenter:______

Client’s Last Name: ______Client’s First Name:______

CAMHD CR#: ______DOB:______Event Date:______Time:______am/pm

 Check here if event occurred when client was not under direct care of program or staff (e.g., family outing, in school, etc.)

 Care Coordinator Notified of Event  Personal Notification of Parent or Legal Guardian

DESCRIPTION OF EVENT

  1. Describe the location and scene (what activity youth(s) engaged in):

  1. Summarize what occurred (attach additional sheet, if necessary):

  1. Precipitating Factors/Antecedents (What happened prior to this event?):
D.Names/titles of participants engaged in this event (submit separate report for other CAMHD youth involved):
E. Any type of follow-up planned for staff or youth witnesses affected by event:

F.How did event end (status of the youth/staff):

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6-01-05 Attachment to Sentinel Event Policy 80.805

CAMHD 72-HOUR SENTINEL EVENT REPORT

EVENT CODES CLIENT CR#: ______

G. Check all that apply (* indicates reporting required only for CAMHD out-of-home placements):

CHILD EVENTS

INSTITUTIONAL EVENTS

FOLLOW-UP, ANALYSIS AND ACTION PLAN CLIENT CR#: ______
This section to be completed by the Clinical Director or designated Qualified Mental Health Professio
  1. Additional post event comments:

  1. Root causes hypothesized (Intrinsic to youth? External – environmental, staff, etc.?):

  1. Could this event have been avoided? How?

  1. Specific changes planned or implemented regarding the youth’s treatment plan, staff, program, physical structure, operations, etc. to reduce the probability of reoccurrence (include results of both debriefing sessions). Check all that apply and provide additional written explanation below:

Narrative:
Clinical Director Print Name: Date:
*If designee, indicate position and discipline title. Phone:______e-mail address:______
Signature:

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6-01-05 Attachment to Sentinel Event Policy 80.805