Incident Management Policy & Procedure
Transcript of 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
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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
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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
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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
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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.
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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:
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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 –
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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.
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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:_________________________________
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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/
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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
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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
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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.
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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.
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Appendix B
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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
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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
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
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
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be cross - checked with the electronic versions
Sample Indicators by Classification Type for Incident Reporting in IRS
(Note - not all-inclusive)
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
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
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
Incident Management Policy & Procedure
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be cross - checked with the electronic versions
Sample Indicators by Classification Type for Incident Reporting in IRS
(Note - not all-inclusive)
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
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
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
Incident Management Policy & Procedure
Page 19 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
Appendix D
Incident Management Policy & Procedure
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be cross - checked with the electronic versions
Appendix E