Sentinel Event: Perinatal events (related to the infant)

From a health care provider perspective (e.g., hospital, physicians practice, long-term care, hospice, home health, surgery center, etc.), write a brief description of the sentinel event in your own words.
In addition, address the following:
    Identify the sentinel event, who was involved, what occurred, and where it occurred.
    Describe the applicable accrediting agencys requirements for reporting the event (e.g., OSHA, ACHA, CMS, CDC, CLIA, The Joint Commission [TJC], AHCA, state agencies).
    Discuss the probable cause that may have contributed to the sentinel event (e.g., process failure, human error, policy error, systems error, technology failure, etc.).
    Create a recommendation that will reduce the risk of future events from occurring.

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Reference
Department of Health and Human Services, Division of Licensing and Certification. (2018). Sentinel events CY2018: Annual report to the Maine State Legislature (Links to an external site.) [Report].
https://www.maine.gov/dhhs/dlc/medical-facilities/sentinelevents/documents/Sentinel-Event-Annual-Report-2018-3-19.pdf