Guided Notes

Incident Reporting

1. Define reportable incidents?

 All incidents, accidents, or occurrences that cause or could cause harm to an
employee, patient, or visitor.
 Video error: didn’t lock the wheelchair so patient fell on the ground (medical risk)

2. List the 7 common incident categories discussed.

 Patient complaints (wait times, communication issues, receiving poor care), difficult
patients (harassment of staff, physical injury to staff), employee injuries (needle stick,
falls, etc.), confidentiality breach (HIPAA privacy or security), *medication error
(wrong med, incorrect dosage), *medical risk (harm to patient, falls, alteration of
medical documents, etc), theft (personal or hospital property).

3. Why should an incident be reported? It is the right thing to do bc accidents happen

 Required by accreditation agency (TJC)
 Hospital policy
 Improve quality of services
 Trend occurrences to determine cause. See if there needs to be retraining or purchase
of new equipment’s.

4. Patient Safety Event: an event, incident, or condition that could have resulted or did
result in harm to a patient.
 A patient safety event can be, but is not necessarily, the result of a defective system or
process design, a system breakdown, equipment failure, or human error.

5. List the four Patient Safety Events and define each.

 Patient safety events also include adverse events, no harm events, close calls, and
hazardous conditions, which are defined as follows:
a. Adverse event: a patient safety event that resulted in harm to a patient
b. No harm event: a patient safety event that reaches the patient but does not cause
harm
c. Close call (near miss): a patient safety that did not reach the patient
d. Hazardous (or unsafe) conditions: a circumstance (other than a patient’s own
disease process or condition) that increases the probability of an adverse event.
Ex: a wet floor with no sign alerting that the floor may be wet

6. Sentinel Event: a patient safety event (not primarily related to the natural course of the
patient’s illness or underlying condition) that reaches a patient and results in any of the
following:
  Death
 Permanent harm
 Severe temporary harm: a potentially life-threatening harm lasting for a limited time
with no permanent residual, but requires transfer to a higher level of care/monitoring
for a prolonged period of time, transfer to a higher level of care for a life-threatening
condition, or additional major surgery, procedure, or treatment to resolve the
condition
 An event is also considered sentinel if it is one of the following:
o Suicide of any patient receiving care, treatment, and services in a staffed
around the clock care setting or within 72 hours of discharge, including from
the hospital’s emergency department
o Unanticipated death of a full-term infant
 Discharge of an infant to the wrong family
 Abduction of any patient receiving care, treatment and services
 Any elopement (unauthorized departure) of a patient from a staffed around the clock
care setting (including ED), leading to death, permanent harm, or severe temporary
harm to the patient
 Hemolytic transfusion reaction involving administration of blood or blood products
having major blood group incompatibilities (ABO, Rh, other blood groups)
 Rape, assault (leading to death, temporary harm or permanent harm) or homicide of
any patient
 “ “ but to a staff member
 Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that
is the wrong (unintended procedure)
 Unintended retention of a foreign object in a patient after an invasive procedure,
including surgery
 Severe neonatal hyperbilirubinemia (bilirubin > 30 milligrams/deciliter)
 Prolonged fluoroscopy with cumulative dose > 1,500 rads to a single field or any
delivery of radiotherapy to the wrong body region or > 25% above the planned
radiotherapy dose
 Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of
patient care
 Any intrapartum (related to the birth process) maternal death or severe maternal
morbidity
These sentinel events that must be reported to The Joint Commission.

7. Summarize the four goals of The Joint Commission Sentinel Event Policy.
1. To have a positive impact in improving patient care, treatment, and services and in
preventing unintended harm
2. To focus the attention of a hospital that has experienced a sentinel event on
understanding the factors that contributed to the event (such as underlying causes,
latent conditions, and active failures in defense systems, or hospital culture), and on
 changing the hospitals culture, systems, and processes to reduce the probability of
such an event in the future
3. To increase the general knowledge about patient safety events, their contributing
factors, and strategies for prevention
4. To maintain the confidence of the public, clinicians, and hospitals that patient safety is
a priority in accredited hospitals.

8. When completing Incident Reports, what are the six must do’s?
1. State the facts, do not draw your own conclusions
2. Complete the entire report – leave nothing blank
3. Write legibly and sign the form
4. Complete the report in a timely manner
5. Never write in the patient’s chart that an incident report was completed – you may
be asked to chart the event but do not mention the report
6. Do not copy the report for your own files

The joint commission: the accrediting body for hospitals and other healthcare entities. They have
a set of standards that must be followed, along with several areas that the hospital or entity must
report.
 Mission: to continuously improve health care for the public, in collaboration with other
stakeholders, by evaluating health care organizations and inspiring them to excel in
providing safe and effective care of the highest quality and value.