FINGERTIP REPORT: E - ADVERSE EVENTS SUMMARY    
PIHP Overall Rate of Sentinel Events per 1,000 Persons Served Rate Arrests & Convictions per 1,000 Persons Served Rate of Unexpected Deaths per 1,000 Persons Served Total Fair Hearing Requests for 10/1/07 - 9/30/08 Rate of Fair Hearing Requests per 1,000 Persons Served Fair Hearing Decisions in Favor of PIHP Fair Hearings Decisions in Favor of Beneficiary Rate: Suicide Rate: Homicide
Access Alliance 4.71 2.36 1.35 12 1.64 0 0    
CMH Affiliation of Mid-Michigan 12.82 8.42 0.00 16 1.94 1 0    
CMH for Central Michigan 0.00 0.00 0.00 12 1.87 1 1    
Detroit-Wayne 0.91 0.58 0.08 13 0.38 0 0    
Genesee 15.10 12.58 0.00 37 5.20 4 0    
Lakeshore Affiliation 2.12 1.06 0.00 15 3.27 0 1    
Lifeways 0.00 0.00 0.00 51 6.54 13 1    
Macomb 0.48 0.00 0.48 60 8.58 11 3    
network180 3.02 1.21 0.60 8 1.13 1 1    
North Country 0.54 0.00 0.00 1 0.19 0 0    
NorthCare 3.09 0.39 1.55 17 2.40 4 3    
Northwest 1.40 1.12 0.28 4 0.82 0 0    
Oakland 0.17 0.00 0.00 25 2.20 2 0    
Saginaw 23.24 22.44 0.80 3 1.00 0 0    
Southeast Partnership 9.71 6.91 0.65 7 1.16 4 1    
Southwest Affiliation 18.78 18.78 0.00 16 2.31 4 0    
Thumb Alliance 1.94 0.00 0.65 9 2.16 2 0    
Venture 10.55 3.25 0.41 17 2.10 5 0    
State Total 4.66 3.32 0.28 323 2.21 52 11    
   
Report produced by: MDCH, Quality Assurance Section
Source data: Submitted Sentinel Event data for the time period 1/1/09 through 3/31/09
File: G:\QMP\Fingertip Reports\Fingertip Reports\Fingertip Report August 2009 Rev 8 6 09.xls
Data extract date:
Report date: 8/6/2009
Notes/Comments: Sentinel Events
A Sentinel Event is an “unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof.  Serious injury specifically includes loss of limb or function.  The phrase, ‘or the risk thereof’ includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.” (JCAHO, 1998)
Population: Reporting is required for Medicaid beneficiaries who, at the time of the event, were the responsibility of the PIHP and 1) living in 24-hour Specialized Residential settings; 2) living in their own homes receiving Community Living Supports; 3) receiving Targeted Case Management, ACT, Home-Based, Wraparound or Habilitation Supports Waiver Services; or 4) residing in a substance abuse residential treatment program.
Reporting: The Department requires PIHPs to submit data on the following types of sentinel events:
·        death of recipient
·        serious illness requiring admission to hospital
·        alleged case of abuse or neglect
·        injury from accident or abuse to the recipient requiring emergency room visit or admission to hospital
·        serious challenging behavior
·        arrest and/or conviction 
·        medication error
Fair Hearing
Fair Hearing Requests are only available for Medicaid Beneficiaries.  Most Fair Hearing Requests are resolved, dismissed, or withdrawn.  Only a small number of the Fair Hearing Requests result in a formal decision in favor of the PIHP or the beneficiary.