How should SPEs be documented and reported?

• A. Submit a report at end of shift.
• B. Only document if patient injury occurred.
• C. Immediately report to the supervisor, document facts, and participate in root-cause analysis per policy.
• D. Report to the patient after discharge.

Answer: (C)

Dealing with sentinel events requires prompt internal reporting and systematic analysis. The best approach is to alert the supervisor immediately, record the facts accurately, and participate in the root-cause analysis per policy. This ensures a timely, objective investigation, helps identify underlying system or process factors, and leads to corrective actions that prevent recurrence. Delaying reporting until the end of a shift misses chances to protect patients and learn from the event; documenting only if an injury occurred ignores near-misses and other risk signals; and reporting to the patient after discharge bypasses internal safety processes that are crucial for timely improvement.