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    Incident Reporting System

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    Ahmed Ibrahim
    1. The document outlines Marshfield Clinic's incident reporting system policy. It defines different types of reportable incidents including general liability, adverse medical device, product recalls, patient risk management, patient experience, patient behavior, medication/chemotherapy, patient privacy, lab/specimen, infection, safety/security/facility, and unprofessional behavior incidents. 2. The policy requires all Marshfield Clinic physicians, providers, residents, and employees who witness an incident to report it using the incident reporting system. Reported incidents must be complete, accurate and timely and require appropriate follow up. 3. Confidentiality of individuals involved in incidents is a high priority. No retaliation will occur against individuals who report incidents or

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Incident Reporting System

    Uploaded by

    Ahmed Ibrahim
    37 views5 pages
    1. The document outlines Marshfield Clinic's incident reporting system policy. It defines different types of reportable incidents including general liability, adverse medical device, product recalls, patient risk management, patient experience, patient behavior, medication/chemotherapy, patient privacy, lab/specimen, infection, safety/security/facility, and unprofessional behavior incidents. 2. The policy requires all Marshfield Clinic physicians, providers, residents, and employees who witness an incident to report it using the incident reporting system. Reported incidents must be complete, accurate and timely and require appropriate follow up. 3. Confidentiality of individuals involved in incidents is a high priority. No retaliation will occur against individuals who report incidents or

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    1. The document outlines Marshfield Clinic's incident reporting system policy. It defines different types of reportable incidents including general liability, adverse medical device, product recalls, patient risk management, patient experience, patient behavior, medication/chemotherapy, patient privacy, lab/specimen, infection, safety/security/facility, and unprofessional behavior incidents. 2. The policy requires all Marshfield Clinic physicians, providers, residents, and employees who witness an incident to report it using the incident reporting system. Reported incidents must be complete, accurate and timely and require appropriate follow up. 3. Confidentiality of individuals involved in incidents is a high priority. No retaliation will occur against individuals who report incidents or

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    37 views5 pages

    Incident Reporting System

    Uploaded by

    Ahmed Ibrahim
    1. The document outlines Marshfield Clinic's incident reporting system policy. It defines different types of reportable incidents including general liability, adverse medical device, product recalls, patient risk management, patient experience, patient behavior, medication/chemotherapy, patient privacy, lab/specimen, infection, safety/security/facility, and unprofessional behavior incidents. 2. The policy requires all Marshfield Clinic physicians, providers, residents, and employees who witness an incident to report it using the incident reporting system. Reported incidents must be complete, accurate and timely and require appropriate follow up. 3. Confidentiality of individuals involved in incidents is a high priority. No retaliation will occur against individuals who report incidents or

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 5

    Incident Reporting System

    Document ID: 3PE3E66MX2CW-2-1140


    Effective Date: 4/22/2016

    Incident Reporting System


    1. SCOPE

    1.1. System-wide, including Marshfield Clinic Health System, Inc. and its affiliated
    organizations who adopt this policy including Marshfield Clinic, Inc., Family Health
    Center of Marshfield, Inc., Lakeview Medical Center, Inc. of Rice Lake, MCHS
    Hospitals, Inc., and all facilities owned and/or operated by the aforementioned
    organizations including all Marshfield Clinic locations, and Marshfield Clinic Regional
    Medical Center; however excluding MCIS, Inc., Marshfield Food Safety, LLC, Security
    Health Plan of Wisconsin, Inc., and Flambeau Hospital.
    1.2. Incidents involving employee health and safety are outside the scope of this policy.

    2. DEFINITIONS & EXPLANATIONS OF TERMS

    2.1. Reportable Incident: An occurrence or event requiring documentation in the


    Incident Reporting System with appropriate follow-up by Marshfield Clinic.
    2.2. General Liability Incident: An accident occurring on any Marshfield Clinic premises
    involving injury to a patient or any visitor resulting from a slip, trip, or fall or other
    event and occurring outside the scope of patient care or related health care
    services.
    2.3. Adverse Medical Device Incident: An event involving death or serious bodily injury
    caused, in whole or in part, by an instrument, apparatus or other article that is used
    to prevent, diagnose, mitigate or treat a disease or to affect the structure or
    function of the body with the exception of drugs. Incidents involving heparin-
    containing flush solutions are considered an adverse medical device incident.
    2.4. Product Recall Incidents: Includes a voluntary or mandatory recall; safety alert;
    notice of product defect, failure or deficiency; or other similar notices issued by a
    manufacturer, vendor, or any federal or state agency and received by Marshfield
    Clinic which may impact the health and safety of Marshfield Clinic patients.
    2.5. Patient Risk Management Incident: Incident with actual or potential medical
    malpractice liability to the Clinic. Risk management incidents include:
     Informed consent issues regarding surgical/medical treatment
     Unexpected , adverse clinical outcome
     Unexpected occurrence during a health care encounter involving patient death
    or serious physical or psychological injury or illness, including loss of limb or
    function, not related to the natural course of the patient’s illness or underlying
    condition
     Surgical or procedural complication
     Unexpected death, medical or surgical or suicide
     Missed/delay in diagnosis
     Obstetrical complication/compromised infant
    2.6. Patient Experience Incident: Patient and/or family concerns regarding the care
    provided to them or their family members at Marshfield Clinic. The care received

    When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
    version.
    Page 1 of 5
    Incident Reporting System
    Document ID: 3PE3E66MX2CW-2-1140
    Effective Date: 4/22/2016

    did not meet the expectations set by the patient. These also include the following
    types of concerns:
     Appointment cancellation or mix-up
     Access issues
     Delay in receiving results
     Excessive waiting time
     Requests to change provider
     Physicians or staff not returning calls
     Duplicate testing
     Initial counseling of disruptive, difficult, drug seeking and noncompliant patient
    behaviors
     Consent issues regarding treatment
     Financial concerns, which are unable to be resolved by Patient Financial Services
    2.7. Patient Behavior Incident: Those incidents where patients have displayed significant
    or recurrent difficult, disruptive, threatening, non-compliant, or drug-seeking
    behavior.
    2.8. Medication/Chemotherapy Incidents: Incidents related to medication, pharmacy
    issues, chemo chemical spills, adverse drug reactions, and chemo medication
    issues.
    2.9. Patient Privacy Incidents: Incidents related to privacy and/or breach of patient
    confidentiality.
    2.10. Lab/Specimen Incident: Incidents involving lab testing/reporting, lost specimens,
    wrong test(s), transport issues, critical values not called and blood product issues.
    2.11. Infection Incidents: Incidents such as airborne isolation breaches, hand hygiene
    compliance issues, patient exposure, communicable disease incidents, sterilization
    issues, suspected infections, or other infection events.
    2.12. Safety/Security/Facility incidents: Incidents related to environment, cleanliness,
    safety, auto accidents on premises, parking, abduction, bomb threats, weapons on
    premises, theft, and property damage/vandalism
    2.13. Unprofessional behavior incidents: Incidents where Marshfield Clinic physicians or
    staff exhibit unprofessional behavior including:
     Abusive or intimidating behavior towards patients, families, or employees
     Defamatory statements
     Destruction, theft or inappropriate removal of clinic property
     Failure to respond
     Intended self-harm or suicide
     Procession of dangerous unauthorized materials (firearms, explosives)
     Practice issues
     Prescribing issues
     Sexual misconduct
     Suspected alcohol or substance abuse

    3. POLICY BODY

    The purpose of this document is to provide expectations for reporting incidents


    occurring at Marshfield Clinic.
    3.1. All Marshfield Clinic physicians, providers, residents, and employees involved or who
    witnessed the incident are obligated to report using the Incident Reporting System.

    When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
    version.
    Page 2 of 5
    Incident Reporting System
    Document ID: 3PE3E66MX2CW-2-1140
    Effective Date: 4/22/2016

    a. If an individual is unsure whether an event requires reporting, they can seek


    guidance from their manager or either the Risk Management or Patient
    Experience Departments.
    3.2. An incident requires reporting through prompt, accurate and complete submission
    of an incident report and requires appropriate follow up with patients and involved
    parties.
    3.3. The incident report will be complete, accurate and timely by the reporting
    employee, physician, provider, or department manager (or his/her delegated
    representative) in the area in which the incident occurred. The benefits of prompt
    reporting include:
    a. Assisting patients and families in real time
    b. Protecting Marshfield Clinic, providers and employees from litigation
    c. Providing the involved professionals with feedback as appropriate.
    3.4. Marshfield Clinic physicians and providers will report hospital-based events, where a
    Marshfield Clinic physician, provider, or staff provided or assisted with the care, to
    the Risk Management team via the Incident Reporting System, as well as to the
    hospital in which the event occurred.
    3.5. Factual information about the event should be documented in the patient’s
    medical record. Documentation in the patient’s medical record will not reference
    incident reporting, legal services, or risk management.
    3.6. Special Condition Alerts in the patient’s medical record will not be mentioned to
    patients or family members.
    3.7. Physicians, providers, and staff will cooperate fully in inquiries and investigations
    concerning incidents.
    3.8. All reported incidents are investigated and resolved.
    3.9. Confidentiality of individuals who are involved and individuals who are reporting is a
    high priority. Information is shared on a need-to-know basis only. The resolution of
    an incident will not be communicated to reporters, in an effort to protect the
    confidentiality of those involved.
    3.10. It is the policy of Marshfield Clinic that no one will be retaliated against for
    submitting an incident report based upon an honest perception of the events or for
    cooperating in good faith in the investigation of an incident. If an employee
    believes he or she is being retaliated against for reporting a concern or
    participating in a related investigation, he or she may report it to their manager or
    the Human Resources department immediately.
    3.11. An investigation of incident does not imply wrong-doing.
    4. ADDITIONAL RESOURCES

    4.1. References:
     Intranet site: http://srdweb1/clinic/incidentRpts/

    4.2. Supporting documents available:


     Incident Reporting System—Risk Management Incident:
    https://documentcontrol.mfldclin.org/sites/legal/Published%20Documents/Incide
    nt%20Reporting%20System%20–%20Risk%20Management%20Incident.pdf
    5. DOCUMENT HISTORY

    When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
    version.
    Page 3 of 5
    Incident Reporting System
    Document ID: 3PE3E66MX2CW-2-1140
    Effective Date: 4/22/2016

    Version No. Revision Description

    1.0 Previously was in Policy Library (policy 4849.0) and was effective on 5/1/12

    Updated to include information on confidentiality and no tolerance for


    2.0
    retaliation. Also to move into Document Control System.

    When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
    version.
    Page 4 of 5
    Incident Reporting System
    Document ID: 3PE3E66MX2CW-2-1140
    Effective Date: 4/22/2016

    6. DOCUMENT PROPERTIES

    Primary Author: Stueland-Adamski, Nancy


    Co-Author(s):
    Approver(s): This document has been electronically signed and approved by: Parkhurst,
    Brandon L MD on: 4/22/2016 10:53:34 AM

    When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
    version.
    Page 5 of 5

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