2. Every event whether sentinel or near miss must be reported at the earliest (within a specified period) on the prescribed format (see annexure 18), giving all the details, by the person first detecting the incident. Failure to report should be treated as breach of discipline. 3. The event so reported will be passed up the channel to the office of the MS and the safety committee without any delay. 4.

Investigations by the Safety Committee without any loss of time. Interim report to be submitted within 24 hours and the final report within 72 hours the investigating team must go into details of the cause and mode of occurrence of the incident, without any distinction whether it is a near miss event or a sentinel event. A root cause analysis carried out scientifically should bring out the weak links including the circumstances of occurrence. 5. Having reconstructed the entire sequence of happening and identified the exact cause and mode, the team should think of the best measures to prevent its recurrence. If it is a system failure then the SOP needs to be reviewed and revised whereas if it is case of human failure, it should be further analyzed to decide whether it was intentional or unintentional due to inadequate knowledge or skills or it was due to carelessness/ negligence.

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6. The team may interview the persons concerned in detail to elicit the exact failure mode. It should be clear to everyone that the first and foremost aim of the investigations is to find out the truth about how and why it happened, so that necessary corrective measures may be taken to prevent its recurrence. Punishment of individuals may become necessary in some situations; however, victimization of any individual should never be the goal of any such investigation. 7. The corrective measures must be evolved after detailed discussion and consultation and then implemented without any delay, after the administrative approval.

8. The report must include, in addition to the recommended measures, the responsibility for implementation by name/designation and the time frame required for effect. It should also include the level of success expected (measurable), after that time frame.

9. After the implementation for the predetermined period (say 3 months), the internal audit committee of the hospital must carry out a detailed review and comparison of the results achieved with the predetermined standards. 10. In case, it is found that the corrective measures implemented have not been effective, additional measures that may be deemed appropriate may be recommended and implemented. 11. The process of review and evaluation must go on until the satisfactory results have been achieved as expected. 12. Although, a sentinel event causing major loss of life or property naturally draws more attention, investigations and serious corrective actions, an adverse event or even a near miss event, too, should be taken seriously.

If this time, an event has caused no injuries or minor injuries, next time we may not be that lucky and the same event may end up in very serious losses.