incident management policy & procedure

Incident Management Policy & Procedure Program/Dept: Quality & Patient Relations Document Category: Quality and Patient

Relations

Developed by: Director Quality & Patient Relations

Original Approval Date:

February 2000

Approved by: Quality Council Reviewed Date: Mar 2007; May 2009; Jul 2012; Feb 2915

Review Frequency: 3 Years Revised Date: December 2017

of 20 A printed copy of this document may not reflect the current, electronic version. Prior to use, paper versions must

be cross - checked with the electronic versions

Purpose

Halton Healthcare is committed to patient safety and continuous quality improvement. The effective

management of safety incidents is an important part of this corporate commitment. All Halton Healthcare

staff, physicians and volunteers are encouraged to be vigilant about identifying and reporting safety

incidents in their everyday practice. The purpose of this policy is to provide direction to those hospital

personnel responsible for and/or involved in incident discovery and reporting, follow-up investigation,

analysis, and learning. Safety incidents provide an opportunity to:

Reflect on practice and our complex environment, allowing us to continually enhance the quality

and safety of the care we provide to our patients;

Learn from the incident;

Prevent recurrences; and

Strengthen the culture of safety at Halton Healthcare

Scope

This policy applies to all physicians, volunteers and staff of Halton Healthcare who become aware of a

safety incident.

Definitions

Safety Incident: An unexpected event or circumstance that could have resulted, or did result in

unnecessary harm to a patient/person, loss or damage.

Incident Management: Is a systematic process for identifying, notifying, prioritising, investigating and

managing the outcomes of an incident and steps taken to prevent similar occurrences.

Incident Analysis: A structured process that aims to identify what, how and why an incident happened,

and what can be done to reduce the risk of recurrence.

Critical Incident: A critical incident is an unintended event that occurs when a patient receives

treatment in the hospital that results in death, or serious disability, injury or harm to the patient, and does

not result primarily from the patient’s underlying medical condition or from a known risk inherent in

providing treatment. Reference: Regulation 965, Public Hospitals Act.

See Appendix A for complete list of definitions.

Incident Management Policy & Procedure



Policy

For the purposes of the policy, Incident Management can be described as proceeding through six (6)

phases. See Appendix B - Algorithm for Incident Management

Adapted from Canadian Incident Analysis Framework, 2012

1. Discovery / Identification

1.1. The situations outlined in Appendix C (Threshold Indicators for Identification and Reporting) are

examples of actual or potential safety incidents. These threshold indicators underscore the

notion that not all incidents are errors and any harm or damage may be unavoidable. These

indicators are examples of potential opportunities in the delivery and improvement of care.

1.2. Families are encouraged to report any safety incidents or concerns upon discovery.

1.3. When a patient-related incident has occurred, as a first priority, staff will ensure that the

immediate needs of the patient and/or family have been met and the person discovering it will:

Initiate appropriate actions to ensure the safety and comfort of the individual and/or

minimize any property damage

Initiate any required care or treatment

Notify the most responsible physician




2. Notification & Reporting

2.1. Notification and Reporting of actual and potential safety incidents must occur as soon as

reasonably practicable after the event.

2.2. Patients and families report any safety incidents or concerns to their direct care providers.

2.3. For serious incidents with actual harm (4 – serious or 5 - death), staff must immediately notify

by phone or pager, the Most Responsible Provider (MRP), direct supervisor and

Manager/Manager-on-call or delegate who then notifies the Program/Department Director. The

Director then notifies the following individuals:

Chief Operating Officer of site where incident occurred

Senior Vice President Clinical Programs and Chief Nursing Executive

Chief of staff

Associate Chief of Staff

Department Chief or Co-Chief

Medical Director

Most Responsible Provider (MRP)

Director Quality and Patient Relations

Others as required (e.g. Professional Practice Leaders, Security Services, Communication and

Public Affairs).

See Leader Checklist on Connections.

(Note that once a serious incident is submitted in the IRS, the system triggers automatic email

notification to the senior leadership team.)

2.4. For non-serious incidents (harm levels 00, 0,1,2,3), staff must notify their direct

supervisor/manager, the most responsible provider (MRP) and complete an incident report.

2.5. The person closest to the incident and/or most familiar with the circumstances shall complete

and submit the on-line safety incident report (Incident Reporting System or IRS): See quick

reference guide on Connections.

Prior to the end of his/her shift for non-serious incidents

Immediately for serious incidents

2.6. When completing the Incident Report, the reporting individual must assign an estimated harm

level and complete all mandatory fields. If the report cannot be completed, for example when

there is missing information or an interruption, the incident is filed as ‘incomplete’ and the

reporter shall return to the incident and complete it as soon as possible.

2.7. Once an incident report is completed and submitted, the manager/delegate will receive an email

alert for all incidents that occur in their area(s) of responsibility. Managers must maintain

vigilance and promptly review the incident and ensure that appropriate remedial and preventive

measures are taken to prevent or minimize recurrence of similar situations.

2.8. Details in both the incident report and the patient record must be factual, objective and concise

without opinion, speculation or blame.

2.9. All relevant clinical care documentation must be recorded in the Patient Health Record.

2.10. In the event that the staff member who is involved in or discovers the incident does not use the

on-line reporting system (for example a staff member in Housekeeping, Food or Volunteer




Services), the paper version (form H3660) is used and the manager enters the incident into the

on-line incident reporting system as soon as possible. See Appendix D – Manual Incident Reporting

Form

2.11. The Program Director and Director of Quality and Patient Relations will lead a Critical Incident

Triage Meeting to determine if the incident meets the definition of “Critical Incident”. For

incidents determined to be ‘Critical’, refer to the Critical Incident Policy & Procedure that

addresses legislative reporting requirements.

2.12. All incidents, regardless of the “Critical” determination will continue through the incident

management process described below.

2.13. Safety incidents can also negatively impact the care practitioners involved - they must also be

supported as part of the incident management process. Upon notification, the Manager/Chief of

Department/Chief of Staff/Director shall identify and address any personal or professional

concerns of staff involved in an incident. This may include:

Arrangements for coverage in the event the staff member is unable to work in the immediate

aftermath of the event;

Identification and provision of supports such as collegial, professional, emotional;

Providing information regarding stress management and the employee assistance program

and facilitating access to counselling as required;

Making available, if appropriate, the opportunity for the individuals involved to participate in a

confidential stress debriefing of the situation. See Appendix A for definition of stress debriefing.

2.14. Disclosure of an incident shall take place with the patient / SDM as soon as practicable after the

incident occurs. (Refer to policy and procedure for ‘Disclosure of Patient Safety Incidents’).

2.15. The Director of Quality and Patient Relations will ensure that the hospital fulfills its regulatory

reporting obligations such as the Coroner and Professional Colleges. If there is a risk of potential

litigation, the hospital insurer, HIROC, will be notified.

Preservation of Evidence

2.16. Any items related to a serious incident (harm levels 4-5), must be secured for testing and for

review by the analysis team. The director or delegate will ensure the following:

Inform Biomedical Engineering if biomedical equipment was involved, who will provide

direction for the removal and transportation of equipment if necessary.

Secure and label any medication or medication containers, packaging, garments, supplies or

equipment that may have been involved in the incident.

In a case involving the Coroner and/or the Police, secure and lock the room and carry out

other activities as directed by the Coroner. See Claims Management Policy and Procedure.

Housekeeping Department shall only clean the areas involved once advised/directed to by the

manager.

3. Investigation & Analysis

For all tools & resources, see Connections under Incident Management and Quality of Care Review Tools and

Resources.




3.1. The Manager of the program/area where the patient was last registered or where the incident

occurred will assume the role of Lead for the investigation by reviewing the incident details and

conducting a preliminary investigation. If more than one department is involved, the Director of

Quality and Patient Relations will takes the lead and facilitates a collaborative effort.

3.2. The review will involve the following:

Review of the Incident Report;

Interview the relevant individuals involved, including patient/family or their authorized

representative 1 (amendment to PHA, Ontario regulation 484/16, 07/2017)

Review additional information such as the Health Record, examination of any items involved

in the incident and of supporting information such as policies, literature or environmental

scans;

Completion of a chronology of events template to determine the sequence of events or

actions.

For serious or critical incidents (Harm levels 4-5), the Program Director will take the lead in

collaboration with the Director of Quality and Patient Relations.

3.3. The Program/Department Director and Director of Quality and Patient Relations will collaborate

to determine the appropriate analysis approach, i.e. whether a systems review and/or individual

accountability review is appropriate. See Appendix E- The Incident Decision Tree. Many incidents

can involve both review types. In the case of individual accountability reviews, the focus is on the

performance of the individual provider(s) and is led by the Program Director in collaboration

with Human Resources and the Vice President Clinical Programs and Chief Nursing Executive. In

these instances, if a system review is deemed necessary, the review must proceed independently.

3.4. The following circumstances must be reported immediately to the Senior Vice President Clinical

Programs and Chief Nursing Executive, Chief of Staff and Director of Quality and Patient

Relations for further action:

Events thought to be the result of a criminal act;

Purposefully unsafe acts where care providers intend to cause harm by their actions;

Acts related to substance abuse by care providers or staff;

Incidents involving patient abuse of any kind.

3.5. Type of Review - The scope and complexity of the incident will determine the type of review

required:

Concise:

Low complexity, low or moderate harm severity; localized to unit/department;

Completed in a short time frame by one or two individuals

Comprehensive:

Complicated and complex incidents where harm is serious or there is significant risk of

serious harm;

Requires significant amount of time and resources and requires an inter-disciplinary

group to meet to support the analysis;

Members of senior team are usually kept apprised of progress or directly involved

Multi-Incident:




this approach is typically used when several similar incidents are reviewed at once; or to

review a group of comprehensive or concise analyses or when multiple patients are

impacted as result of one situation/event

4. Conducting and Documenting a Quality of Care Review (QCR)

A Quality of Care Review can be conducted under the ‘Quality of Care Information Protection Act

(QCIPA)’ legislation or not. This legislation provides the ultimate shield for protection of all quality of

care information prepared for or by a Quality of Care Committee. It does not protect the facts of the

case, whether or not they are documented in the patient record.

4.1. If the Program identifies a requirement for the review to proceed under QCIPA, the Program

Director and Physician Chief require the designation by the Chair of the Corporate Quality of

Care Committee through issuance of a direction in writing to the Quality of Care Review

Committee Chairs.

4.2. For all comprehensive reviews (with or without QCIPA), the Program/Department Quality of

Care Review Committees will utilize the following tools available on connections:

Agenda

Goals and Objectives of QCR

Opening Script QCR

Minutes/Recommendations Template,

Incident Analysis Guide/checklist/template

(Note that similar templates are available when it is determined that a review is to be conducted

under QCIPA and will be available on request from the Director of Quality and Patient

Relations.)

4.3. A Quality of Care review is conducted with participation of the care providers involved and

should include the Patient Relations Advisor or designate who can provide the patient

perspective during the review (amendment to PHA, Ontario regulation 484/16, 07/2017)

4.4. The review should proceed, utilizing where possible a standardized approach to analysis.

4.5. The lead manager/director will convene an interdisciplinary review team once the preliminary

findings and a detailed timeline are determined. The lead for the review will ensure that all

participants have been provided with relevant information related to the case and their role as a

participant in the review.

4.6. At the conclusion of the review the team will develop recommendations using the SMART

format: Note in some instances, analyses may not generate any new recommendations.

Specific – tackle a clearly defined issue that has clear scope;

Measurable – can demonstrate impact on process and outcomes;

Attainable – can be achieved within available resources;

Realistic – is it likely to be accepted/implemented;

Timely – should have a timeline for implementation.

4.7. Each recommendation will have an order of priority, accountabilities and time-line for

completion of each action item.

4.8. Minutes and recommendations will be shared as follows:

For Quality of Care reviews outside of QCIPA –




o Program/department Director will circulate for endorsement by the review team. These are

then returned to and kept by the program/department director who will send a copy to the

Director of Quality and Patient Relations.

For Quality of Care reviews under QCIPA –

o All documents will be returned to the Director of Quality and Patient Relations.

Director of Quality and Patient Relations maintains a corporate repository of all

recommendations and communicates these for review with the Corporate Quality of Care

Committee.

4.9. Timelines for initiation and completion/closure of an incident investigation is dependent on the

circumstances and harm/damage level as follows:

L00, L0 and L1 (Reportable Circumstance, Near Miss, No Harm/Damage):

- Within one month or less

L2 and L3 (Minor, Moderate Harm/Damage):

- Within one month or less

L4 and L5 (Serious Harm/Damage, Death harm):

- Review initiated as quickly as possible; completion/closure within 3 months

5. Follow-through: Implement, Monitor, Assess Recommendations / Action Items

5.1. This step involves implementation of the key recommendations/action items, monitoring and

evaluating the effectiveness of the actions implemented.

5.2. The manager/director provides a quarterly status update to the specific Program/Department

Quality of Care Committee and to the Director, Quality and Patient Relations Director.

5.3. The Corporate Quality of Care Committee reviews the status of recommendations on a

monthly basis and tracks achievement towards full implementation of recommendations with the

operational leadership at each site.

5.4. The Director of Quality and Patient Relations will collaborate with the Program/Department

Director to determine who will contact the patient/family about the progress of actions and

recommendations.

6. Closing the Loop

6.1. Completing/Resolving the Incident Report –

On completion of the investigation and follow-up, the manager who is ultimately responsible will:

Document final actions in the ‘Review/Resolution’ screen/form

Close and sign off all incidents for all harm levels within 3 months of the incident, recognizing

that some may take longer than others where there are mitigating circumstances.

6.2. Continuous Learning and Sharing Results –

Learning from an incident, understanding and articulating what can be done to prevent its

recurrence and heal relationships are the ultimate goals of the Incident Management process.

Sharing the learning and communicating both externally and internally where appropriate is

important.




Managers/Directors will share their unit/program leanings with staff, physicians, and

volunteers within their programs/departments as well as across the organization where

similar system-wide opportunities for improvement exist. However, in order to ensure

confidentiality, any specific details of the incident that might link the learning or

recommendation to a specific incident/situation should be avoided.

6.3. If an incident is determined to be a critical incident, refer to the Critical Incident Policy and

Procedure for additional requirements.

6.4. The Quality and Patient Relations department will make available to the leadership team a

number of tracking reports from the IRS.

Supplies

Incident Management Resources on Connections

Roles/Responsibilities

As outlined in the policy above

Related Documents

Disclosure of Patient Safety Incidents

Critical Incident Policy

Claims Management Policy & Procedure

Key Words

Patient Safety, Incident, disclosure, critical incident, analysis, framework, harm, severity level

Reviewed by

Program Steering Committees

Patient Safety Steering Committee

Quality Council

Ethics Forum

Medical Advisory Committee

Signed by: ________________________________ Title:_________________________________




References

Accreditation Canada. (2017). Required organizational practices: Handbook 2017_V2 – January 2017.

Retrieved from

https://www3.accreditation.ca/OrgPortal/Documents/Resources/AddResources/ROPHandbook_2017

_v2_EN.pdf

Canadian Patient Safety Institute. (2012). Canadian incident analysis framework. Retrieved from

http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Documents/Canadian%2

0Incident%20Analysis%20Framework.PDF

2017. New QCIPA and Hospital Management Regulations. Changes – coming into Force July 1, 2017.

BLG. Retrieved from http://blg.com/en/News-And-Publications/Publication_4820

Institute for Safe Medication Practices Canada. (2015). Ontario critical incident learning. Retrieved from

http://www.ismp-canada.org/ocil/

Ministry of Health and Long-Term Care. (2011). About Excellent Care for All Regulations. Update as of

November 2017 care for all act updates: Retrieved from https://www.ontario.ca/laws/statute/10e14

National Health Service Confederation/National Patient Safety Agency. (2005). The incident decision tree:

Guidelines for action following patient safety incidents. In Henriksen, K., Battles, J.B., Marks, E.S.

. . et al. (Eds.), Advances in patient safety: From research to implementation (Volume 4: Programs,

Tools, and Products. Rockville (MD): Agency for Healthcare Research and Quality (US).

Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK20586/

Service Ontario e-Laws. (2014). Public hospitals act. Retrieved from

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90p40_e.htm

World Health Organization. (2015). A taxonomy for patient safety. Retrieved from

http://www.who.int/patientsafety/implementation/taxonomy/en/

https://www3.accreditation.ca/OrgPortal/Documents/Resources/AddResources/ROPHandbook_2017_v2_EN.pdf

https://www3.accreditation.ca/OrgPortal/Documents/Resources/AddResources/ROPHandbook_2017_v2_EN.pdf

http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF


http://blg.com/en/News-And-Publications/Publication_4820

http://www.ismp-canada.org/ocil/

https://www.ontario.ca/laws/statute/10e14

http://www.ncbi.nlm.nih.gov/books/NBK20586/

http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_90p40_e.htm

http://www.who.int/patientsafety/implementation/taxonomy/en/




Appendices

Appendix A Definitions

Appendix B Algorithm for Incident Management

Appendix C Threshold Indicators for Reporting/Tracking and Quality Improvement Reviews

Appendix D Safety Incident Report (Downtime)

Appendix E Incident Decision Tree




Appendix A

Definitions

Incident Reporting System – As part of the Risk Management Program, the Hospital uses Risk

Monitor Pro© or the Incident Reporting System (IRS) as an on-line system for all incident and

person/non-person involved types, including ‘employee’ incidents. It is a voluntary system, similar to

systems used across Canada. It allows for the reporting, notification, tracking, trending and performance

evaluation of safety incidents across the organization.

Harmful Incident: A patient safety incident that resulted in harm to the patient. Replaces “adverse

event”, “sentinel event”.

Harm Levels:

L00 - Reportable circumstance: A harm type that does not involve a ‘person’ at all but relates to a

process that is a ‘risk’ e.g. a hole in wrapper of sterile tray, incorrect narcotic count.

L0 - Near Miss: An incident that did not reach the patient or take place (replaces “close call”, “safe

catch”).

L1 - No Harm Incident: A safety incident that reached a patient, but no discernible harm resulted.

L2 - Minor Harm: Patient outcome /situation is symptomatic, symptoms are mild, loss of function or

harm is minimal or intermediate but short term and no or minimal intervention is required. (e.g. extra

observation, investigation, or minor treatment)

L3 - Moderate Harm: Patient outcome /situation is symptomatic, requiring intervention (e.g.

additional operative procedure or therapeutic treatment) or an increased length of stay, or causes

minor long term harm or loss of function.

L4 - Serious Harm: Patient outcome is symptomatic, requiring life-saving intervention or major

surgical/medical intervention, or shortening life expectancy or causing major permanent, long-term

harm or loss of function.

L5 – Death: On balance of probabilities, the incident may have played a role in the individual’s death.

Disclosure: The process by which a patient safety incident is communicated to the patient, substitute

decision maker or legal representative by healthcare providers or the acknowledgement and discussion of

a negative outcome with the patient and/or his/her authorized Substitute Decision Maker (SDM). See

policy ‘Disclosure of Patient Safety Incidents.

Quality of Care Committees:

i. Corporate Quality of Care Committee (QCC): This committee is established by the

hospital pursuant to the QCIPA legislation whose functions are to guide activities regarding critical

safety incident reviews for the purpose of studying, assessing or evaluating the provision of health

care with a view to improving or maintaining the quality of health care, or the level of skill,

knowledge or competence of the persons who provide the health care. This committee may

designate a review by the local Program Quality of Care Committee. Reference: Corporate Quality

of Care Committee Terms of Reference

ii. Quality of Care Review Committees (QCRC): Quality of Care Review Committees

(QCRC) carry out activities for the purpose of studying, assessing or evaluating the provision of




health care in their area in order to improve or maintain the quality of healthcare, or the level of

skill, knowledge and competence of the persons who provide health care within the program. The

QRQC reports through its chair(s) to the Chief Operating Officer/ Senior Vice President Clinical

Programs and Chief Nursing Executive.

iii. Critical Incident Triage Committee: This committee meets as needed to determine if a

serious safety incident meets the definition of a ‘critical incident’ as per the Ontario legislation

(PHA 965) and provides recommendations to the corporate Quality of Care Committee and the

Program Quality of Care Committee. See policy statement 2.10.

iv. Quality of Care Review (QCR): Any review of the provision of health care to a patient or a

group of patients with a view to improving or maintaining the quality of health care or the level of

skill, knowledge, and competence of the persons who provide the health care. A Quality of Care

Review shall be initiated for any incident or near miss that gives rise too significant quality of care

concerns, including but not limited to:

An incident involving unexpected death or serious bodily harm or damage

An incident or series of incidents that have the potential to result in death or serious bodily

harm, or damage;

An incident or series of incidents that have the potential to result in harm to a number of

patients or damage;

An incident where employees, patient or family/caregivers express significant concerns

regarding quality or safety of care.

Quality of Care Information Protection Act (QCIPA)

The Quality of Care Information Protection Act (“QCIPA”) was introduced in November of 2004 and

revised in July 2017. This legislation was created to facilitate open dialogue between care providers by

protecting that dialogue from disclosure. Only quality of care information that is provided to or produced

by a designated Quality of Care Committee is protected. The QCIPA legislation places privilege over the

discussions that occur in a Quality of Care Review but does not protect facts related to the patient

incident or the care (OHA, 2004).

Risk: The probability of danger, injury, damage, loss, liability or undesirable outcome within the

healthcare system

Systems Approach: This ‘systems approach’ to incident reviews recognizes that human performance is

greatly influenced by environmental or system factors including those related to the patient (e.g.

complexity, ability to communicate), the workplace (e.g. working conditions), and the organization (e.g.

priority setting). When problems are identified, these broader aspects of the system are explored to

determine whether they had an influence on the incident and to determine what changes could be made

to prevent similar events from occurring in the future.




Health Care Providers Involved in Incident: A health care provider who is involved in patient safety

incident, in a medical error and/or a patient related injury and becomes victimized in the sense that the

provider is traumatized by the event. (Agency for Healthcare Research and Quality, 2011)

Stress Debriefing: Is a semi-structured conversation with an individual or group that has just

experienced a stressful or traumatic event to reduce any possibility of psychological harm by allowing

discussion of the event. These discussions will be held in confidence with the exception of the facts of the

situation and / or contained in the health record and will not be minuted.

Substitute Decision Maker (SDM) Person authorized under the Healthcare Consent Act, 1996 to

give or refuse consent to treatment on the incapable person’s behalf. The SDM is the highest ranking

individual who meets the requirements set out in the legislation and who is available and willing to assume

the responsibility of giving or refusing consent.

http://en.wikipedia.org/wiki/Traumatic_event_(psychological)




Appendix B




Incident Management

Indicators for Reporting/Tracking and Quality Improvement Reviews

The following list outlines actual or potential incidents or a series of incidents or outcomes that may

warrant reporting in the IRS and a formal quality of care review if the result is an actual or potential

unexpected death or serious bodily harm/damage or risk of same.

Additionally, a review is recommended when:

When employees, patient or family/caregivers express significant concerns regarding quality or safety

of care

At request of the corporate Quality of Care Committee

The following types of incidents are not recommended for a quality of care review until other external

reviews are completed:

Events thought to be the result of a criminal act;

Purposefully unsafe acts (an act where care providers intend to cause harm by their actions);

Acts related to substance abuse by provider/staff; and

Events involving suspected patient abuse of any kind

Sample Indicators by Classification Type for Incident Reporting in IRS (Note - not all-inclusive)

Strongly

Recommended for

Review

Med-Fluid related incidents e.g.

Allergic reaction

Failure to monitor

Missed dose/extra dose

Drug-drug interaction

Incorrect/incomplete narcotic

count

Infiltration / Extravasation

Wrong

dose/frequency/route/time

Several others….

Any incident / series of

incidents involving:

unexpected death or

serious bodily harm /

injury / damage

the potential to result

in serious bodily

harm/death to a

patient or number of

patients

Fall

While ambulation to washroom

On stairs

From bed / crib / over rails

On stairs

While being held y caregiver

From stretcher or equipment

Chair/Stool/wheelchair

Transfer/lift

Shower, tub

Toilet/commode

Diagnostic Test (not Lab) e.g.

Reporting delayed

Extravasation

Adverse reaction

Lost image

Missed fracture

Requisition incorrect/incomplete

Follow-up inadequate

Test results not

completed/delayed

Delayed critical result

Missed malignancy

Tissue trauma from test Transcription issue

Lab / Blood Product e.g.

Adverse reaction

Delay in critical test results

reporting

Appendix C




Sample Indicators by Classification Type for Incident Reporting in IRS

(Note - not all-inclusive)

Strongly

Recommended for

Review

Labeling issues (several…)

Quality control issue

Results posted to wrong pt

Armband not on pt/wrong pt

Result not reported

Results posted to wrong patient

Lost results

Lost specimen

Transfusion issue

Unordered test performed

Wrong results reported

Wrong test done



unexpected death

or serious bodily

harm/injury/damage

the potential to

result in serious

bodily harm/death

to a patient or

number of patients

Treatment-Procedure/Care e.g.

Adverse reaction

Line/tube issue

Count discrepancy

Anaesthesia issue

Airway management

Cardiac arrest

Outcome/complication

Additional indicators

Hospital-acquired infections

Deaths that occur within 48 h after

surgery

Retained instruments

Death while out on a ‘pass/LOA’ or

within 72 hours of being discharged

Pediatric –

Transfer to a tertiary centre

Blood transfusion required

Re-admitted within 7 days of

discharge from hospital

Vascular access issue

Failure to prevent suicide

Retained foreign item

Delay/lack of response

Positioning

Procedure-related issue

Wrong patient

Wrong side/site/body part

All unexpected transfers: PACU

to ICU

Patients experiencing respiratory

arrest in the PACU

Death within 24h of transfer to

ICU

Transfer to ICU from

Ambulatory area

Mental Health Suicide or Unexpected death –

o while admitted to the inpatient or

day treatment programs

o within 2 weeks of an inpatient or

day treatment discharge

o within one week of a crisis team

assessment and/or psychiatrist

assessment in the emergency

department

Violence or Aggression –

o resulting in serious injury, harm

or disability to self, a co-

patient, visitor or staff in any of

the above scenarios

o resulting in significant damage

to property

Unanticipated /missed serious

medical illness or deteriorating

medical status in inpatient mental

health unit

Safety Security e.g.

Abuse/assault

Accidental injury

Auto damage

Property damage/vandalism / loss

Property / equipment faulty

Self-injury

Restraint use






Strongly

Recommended for

Review

Biohazard containment

Elevator entrapment

Disorderly person

Fraud / attempted fraud

Theft/suspected theft

Unauthorized drugs/weapons,

smoking

All the CODES (12) –Amber /

Black /

Emergency Codes All CODES (12) – Amber / Black

Brown / Green /Grey (5) /

Orange / Pink / Purple / Red /

White / Yellow / Blue

Mat Childbirth e.g.

Birth trauma/death – baby

Birth trauma/death – mother

Maternal / neonate complication

Cord prolapse

Shoulder dystocia

Mat Childbirth (continued)

Hepatitis B status unknown

Strep B infection

Surgical complication

Physician not present at delivery

Membrane rupture-prolonged, no

antibiotics

Low Apgar - < 6 at 5 minutes

Ante/postpartum hemorrhage > 1000

mL Additional Indicators

Cardio-pulmonary arrest

Inverted Uterus

Adverse obstetrical surgical outcome

(e.g. hysterectomy, unplanned

removal or repair of organs)

Anesthesia related complications with

significant maternal or fetal

compromise

Maternal admission to ICU

Uterine rupture

Unattended delivery with poor

neonatal or maternal outcome

Stillbirth (unusual circumstances)

Eclampsia/seizures

Cord prolapse with poor

neonatal outcome

Forceps/vacuum with maternal

and/or neonatal injury

Disseminated Intravascular

Coagulopathy (DIC)

Pulmonary embolism

Amniotic Fluid Embolism

Delivery at less than 32 weeks

gestation

Neonate delivered at less than

1500 grams

Neonate with Apgar scores < 5

at 5 min

Transfer of neonate to tertiary

centre

Any Code Pink

Discharge to wrong person

Fetal pH < 7.0

Cord pH < 7.0



unexpected death

or serious bodily

harm/injury/damage

the potential to

result in serious

bodily harm/death

to a patient or

number of patients

Environment e.g.

Blocked/obstructed area

Bed malfunction

Cleanliness

Walking surface

Construction issue

Elevator malfunction

Improper storage

Noise, lighting, temp

Disruption of power

or other essential

services resulting in

an actual or potential






Strongly

Recommended for

Review

Disaster

Equipment issue

Water leak/flood serious patient

outcome

Infection Control e.g.

Break in isolation

Break in sterile technique

Exposure blood /body fluid

Exposure communicable disease

Exposure hazardous material

Failure to isolate

PPE issue

Sharps issue

Single-use item submitted for

reprocessing

Sterilization/disinfection

HAIs



unexpected death or

serious bodily

harm/injury/damage

the potential to

result in serious

bodily harm/death to

a patient or number

of patients

Information Integrity e.g.

Disclosure issue

Consent unsigned

Patient identification

Registration process

Police communication

Computer access

Documentation

Media communication

Transcription

Verbal orders

Pressure Ulcer (nosocomial) e.g.

Stages 1-2-3-4

Unstageable

Suspected deep tissue injury

References: Canadian Patient Safety Institute. (2012). Canadian incident analysis framework. Retrieved from

http://www.patientsafetyinstitute.ca/English/toolsResources/IncidentAnalysis/Documents/Canadian%20Inci

dent%20Analysis%20Framework.PDF






Appendix D




Appendix E