Incident Reporting Policy

Including but not limited to Patient/Client Serving Clinics, Visitors, and Tours College of Health Professions

Approved by the College of Health Professions Executive Council on February 13, 2018

  1. Purpose

    To define incidents involving unsafe actions or conditions, which create potential or actual, harm to patients/clients, visitors, staff, faculty or students. The reporting and documentation of incidents furnishes essential data used to assist programs to follow-up, analyze and resolve incidents to reduce future adverse outcomes and/or unsafe conditions. This policy provides guidelines for correct notification, documentation, reporting, and evaluation of such incidents.

  2. Event Definitions

    For purposes of this Policy, a harm event is generally defined as a suspected or actual variation in a health care delivery process during which the patient/client/visitor is affected. Any event that fits into this broad category, whether or not listed below, is considered a reportable event and subject to this Policy.

    • Medication Event: Any event that could cause or lead to a patient receiving inappropriate drug therapy, failure to receive appropriate drug therapy, or any unexpected outcome related to drug therapy. Medication incidents include, but are not limited to, Adverse Drug Reactions.
    • Adverse Drug Reaction: An adverse drug reaction (ADR) is any unintended, undesired, and unavoidable noxious effect of agents administered to patients/clients for diagnostic, prophylactic, or therapeutic indications.
    • Sentinel Event: Any event that results in, or involves the risk of, death or major permanent loss of function (e.g., serious physical or psychological injury) not related to the course of a patient's illness or underlying condition. The phrase "or risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
    • Non-Health Care Related Event: Any unsafe condition or event involving a patient, client or visitor occurring on the grounds of the patient serving clinic (or any other location assigned to the College of Health Professions) but unrelated to care/services being provided to the patient by the clinic staff, residents, faculty, or students.
    • Unsafe Condition: any event that involves a violation or deviation from the standards of care and/or the code of ethical practice for that profession.

  3. Who Must Follow This Policy?

    This policy applies to all employees, students and volunteers (collectively referred to as "staff") in each of the patient-serving clinics in the College of Health Professions:

    • Evelyn Hendren-Cassat Speech-Language-Hearing Clinic

    • Delta Dental of Kansas Foundation Dental Hygiene Clinic

    • Delta Dental of Kansas Dental Clinic, Advanced Education in General Dentistry

    • Audiology Clinic in Hubbard Hall

    • Any other location assigned to the College of Health Professions

  4. Reporting Responsibility

    Staff involved in or aware of any event or unsafe condition has a responsibility to document the incident and report it to their Clinic Director/Department Chair.

    • Staff must report any event and/or unsafe condition to the appropriate Clinic Director/Department Chair within 24 hours of the event/unsafe condition.

    • If necessary, staff must provide immediate medical care which may include, but is not limited to first aid and emergency care.

    • All reporting and analysis of patient/client incidents is confidential. Anonymous reporting of incidents is allowed.

    • The supervising faculty member must communicate any unanticipated outcomes to the affected patient/guest and family.

    • The Clinic Director/Department Chair must review all event reports within 72 hours of the event and/or unsafe condition (excluding weekends, holidays or extenuating circumstances) and must evaluate the event and record his or her intervention(s) on the Patient/Client Event Form.

    The Clinic Director/Department Chair, in consultation with the Dean of the College of Health Professions, has the discretion to determine the timing and need for additional reporting. Examples include, but are not limited to Wichita State University General Counsel, professional liability insurance carriers, etc.

  5. Documentation

    1. In addition to reporting responsibilities, staff must provide the proper documentation of any event and/or unsafe condition.
    2. For incidents involving patients/clients, staff must:

      • Update Medical/Dental Record. Be sure to include a factual description of the event, the patient's response, and treatment provided.

      • Submit Patient/Client Event Form (see attached) to the appropriate the Clinic Director/Department Chair

      • For incidents involving staff or faculty, submit an Employee Accident or Illness Report
    3. For individuals who have knowledge of a WSU student or student organization violating the Student Code of Conduct or another University policy, Utilize the WSU Incident reporting Form

  6. Follow-up Process

    Once submitted, the Clinic Director/Department Chair is responsible for conducting and managing all follow-up, as appropriate. Such follow-up may include, but is not limited to:

    • Meeting with all parties involved to identify preventive measures and roots cause(s)

    • Documenting any findings

    • Determining implementation of additional safeguard measures (e.g., change in work or care area process, training of the individual, revision of clinic specific standards of care, or conferring with leadership for input)

    • Identifying potential system-based contributing factors

    • Addressing any individual education, process improvement, competency, or behavior issues (and provide support as appropriate)

    • Forwarding event reports to relevant faculty for follow-up

Attachments:

  1. Instructions for Completing the Patient/Client Event Form

  2. Patient/Client Event Form

     

  3. Instructions for Completing the Patient/Client Event Form

  4.  

    Incidents Involving Patients/Clients/Visitors

    • The person completing the Patient/Client Event Form should be the individual who witnessed, first discovered, or is most familiar with the incident.

    • The report should be immediately presented to the reporter's Clinic Director/Department Chair who must then investigate and recommend corrective action.

    • Description of the incident should be a brief objective description of the facts; it should not include the writer's judgment as to the cause of the event.

    • Quotes should be used where applicable with unwitnessed incidents, e.g., "Patient/Client states..."

    • Names of any witnesses should be included; name of the employee directly involved in the incident can be recorded in the witness space as well, if the employee is not the reporter.

    • The patient must be examined by an appropriate provider.

    • The Patient/Client Event Form should be completed no later than the end of the shift during which the incident occurred or was discovered to have occurred and should be forwarded to the Clinic Director/Department Chair within 24 to 48 hours.

    • The Patient/Client Event Form is an administrative document, not part of the medical record. The fact that a Patient/Client Event Form has been completed should not be reflected in the medical record, nor should the report be placed in the medical record.

    • No copies of the Patient/Client Event Form should be made.

       

      Incidents Involving a Medical Device

    • Report the incident to the Clinic Director/Department Chair

    • Fill out a Patient/Client Event Form

    • Record the manufacturer, model number, serial number, and control number of the equipment on the incident report

    • Save the original packing if possible

    • When equipment is involved, impound the equipment, the disposable product used with the equipment, and the packaging materials from the disposable product

    • Tag the equipment with a sign that states "EQUIPMENT BROKEN - DO NOT USE".

 

Submit the completed Patient/Client Event Form to the appropriate the Clinic Director/Department Chair.

  • Patient/Client Event Form

 

Today's Date:

 

Location Where Event Occurred:

 

Date Event Occurred:

 

Patient/Client Information:

 

What Is Your Name and Role?

How Were You Involved in This Event? Type of Event:

  1. Incident: A patient safety event that reached the patient, whether or not the patient was harmed.

  2. Unsafe Condition: Any circumstance that increases the probability of a patient safety event.

  3. other (please describe) List of Witnesses:

Event Result:

 

Please describe the event in the space provided:

 

Provide your opinion as to the cause of the patient/client safety event:

 

Please provide any suggestions that would prevent another similar event.:

 

If the prevention or mitigation suggestion has been implemented, please report the number of weeks that occurred between the identification of the mitigation and the implementation of the mitigation.

 

If the failure or malfunction of a device or piece of equipment is integral to or caused the event, please fill in the following information:

 

Type of device or piece of equipment:

  • Manufacturer

  • Model Number

  • Approximate age of device or equipment

 

Submit the completed Patient/Client Event Form to the appropriate the Clinic Director/Department Chair.