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Sentinel event reporting form

Sentinel event form 2026

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The Maine Sentinel Event Notification and Near Miss Reporting Form is a required document for reporting sentinel events or near misses in healthcare settings, as mandated by state regulations. It includes sections for detailing the event, patient information, and specific types of incidents that need to be reported. The form emphasizes the importance of timely notification within one business day and provides guidelines on various serious reportable events, ensuring confidentiality and compliance with healthcare standards.

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Click ‘Get Form’ to open the sentinel event form in the editor.
Begin by filling out the 'What is being reported?' section, selecting either 'Sentinel Event' or 'Near Miss'.
Enter today's date, date of discovery, date and time of the event, and if applicable, the date of death.
Provide the patient's age and gender. Specify the admitting diagnosis for clarity.
In the description field, briefly outline the event including its location to provide context.
Check all applicable types of events from the list provided, ensuring you capture all relevant details.
Answer yes or no to questions regarding unanticipated deaths, transfers, and NQF criteria compliance.
Complete reporter information including name, title, contact number, email address, and facility name.

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Versions	Form popularity	Fillable & printable
2023	4.9 Satisfied (30 Votes)
2014	4.4 Satisfied (27 Votes)

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