Overview

As part of the organization's risk management and health and safety practices, incident reporting should occur for adverse and sentinel events, reports of incidents to the proper authorities, and records of incidents so they can be analyzed for trends and future incident reduction. Timely debriefings following critical incidents should be conducted following emergency events.

Accreditation Requirement(s)

To meet the intent of the standards related to critical incident reporting, the organization must comply with the following:

• Incidents should be reported for adverse events (such as injuries, serious illnesses, violence or aggression, theft, property damage, natural disasters, medication errors, contraband, transportation incidents, etc.), alleged cases of abuse, neglect and exploitation, seclusion and/or restraint, communicable diseases/biohazardous materials, and sentinel events ("an unexpected occurrence involving death or serious physical or psychological injury or risk thereof. Serious injury specifically includes loss of limb or function. The phrase 'or risk thereof' includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome" [CARF 2003-2004 Standards Manual, Glossary, p. 141]).
• Incidents should be recorded and reported to the proper authorities, as appropriate (e.g., per regulation of state licensing boards and accreditation bodies for sentinel events).
• Incidents are analyzed for trends and patterns so that an action plan can be developed and that potential of future risk is reduced. The report to leadership should include causes, trends, planned actions for improvement, results of actions taken, prevention, education and training of personnel, and satisfaction of internal and external reporting requirements.
• For serious emergency situations (e.g., terrorist threat, suicide/death of client or staff person, some workplace violence incidents), the organization should conduct debriefings for staff in order to provide support for them.

Implementation Tips

Some Implementation Tips provided, in part, by Robert Johnson at: www.accreditationnow.com.

• Incident reports are risk management tools. They are designed to provide a summary of an incident that may not otherwise be documented. The report should provide information about the incident and what actions the organization took in response to it. The written report should not interpret events; it should focus on the objective, observed facts and parties involved. The monitoring of these reports helps the organization understand patterns and look for ways to minimize serious incidents that may be harmful to clients, staff, and visitors. Proper incident reporting protects the interest of all parties. An entry in the clinical/medical record does not substitute for a formal reporting of an incident. In fact, in most cases incident reports should not be filed in the clinical/medical record, in the event that record is ordered into a courtroom for testimony.
  
  
• The determining factor for deciding whether or not to classify an event as an incident is if there is the possibility of litigation resulting from the event. Incidents refer to actions that involve staff members and visitors, as well as clients. Incident forms are used to record significant incidents for accountability and liability purposes, as well as to identify possible contributing factors, which resulted in the incident.
  
  
• Original incident reports are usually kept in a locked file cabinet in the office of the person responsible for them (e.g., Quality Improvement Director, program/clinic manager, Division Director). The appropriate person should maintain incident reports for a number of years, depending on organizational policy or state regulations.
  
  
• Often, state licensing authorities have expectations of when and what types of incidents should be reported to their office. Ascertain and follow your state regulations related to reporting.
  
  
• Debriefings of crisis situations usually are conducted by the organization's internal crisis response team, trained clinicians, or by external community providers. Some programs have written agreements with Employee Assistance Programs that provide this service.
  
  
• Always debrief with staff to ensure that you respond to their needs related to the incident. This should be done as close to the event as possible.
  
  
• Leadership should receive detailed analyses of all critical incidents. These summaries may provide leadership with data and other input that can be utilized for performance improvement purposes.