Incident Reporting Policy Overview
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Questions and Answers

What is the primary aim of the Incident/Accident Reporting policy?

  • To ensure all incidents are ignored to maintain morale.
  • To limit information shared with external parties.
  • To focus solely on financial implications of incidents.
  • To provide a fair and just culture aiding in reporting. (correct)

Who is responsible for reporting adverse incidents according to the policy?

  • Contractors are exempt from reporting.
  • All staff, including interns and voluntary workers. (correct)
  • Only full-time employees.
  • Exclusively hospital administrators.

What is required of all incidents or accidents reported?

  • They must be acted upon within 24 hours. (correct)
  • They should only be reported if they involve media.
  • They should be acted upon within 48 hours.
  • They must be ignored if not severe.

What type of approach does the policy promote for problem resolution?

<p>System-centered approach. (D)</p> Signup and view all the answers

What should be maintained by the Hospital Administrator regarding incidents?

<p>An Incident Report File. (C)</p> Signup and view all the answers

What is not a purpose of the Incident/Accident Reporting policy?

<p>Establish an unchangeable reporting hierarchy. (C)</p> Signup and view all the answers

How should all incidents reported involving media issues be communicated?

<p>In writing to Ministry of Health Officials. (B)</p> Signup and view all the answers

What aspect does the policy emphasize maximizing?

<p>Opportunities for improvement. (A)</p> Signup and view all the answers

Which of the following statements accurately describes the initial step in managing an incident?

<p>Assess the injured person or damaged property to determine the severity of injuries. (A)</p> Signup and view all the answers

What should be done when an incident involves more than one department?

<p>Each affected department should independently rate and record the event. (D)</p> Signup and view all the answers

Which method is NOT one of the ways incidents can be identified aside from reporting forms?

<p>Incident management training (A)</p> Signup and view all the answers

When using patient feedback to identify events, what is a common concern regarding patient perception?

<p>Patients are unable to adequately judge the quality of clinical services. (A)</p> Signup and view all the answers

What is required of each approved policy concerning incident reporting?

<p>A checklist must be developed for auditing its effectiveness. (A)</p> Signup and view all the answers

What should be the course of action if a patient error occurs?

<p>Contact the relevant medical team for assessment. (D)</p> Signup and view all the answers

What information can be obtained from conducting patient satisfaction surveys?

<p>Valuable data for improving healthcare systems. (C)</p> Signup and view all the answers

Which incident reporting procedure is focused on the severity of incidents affecting the organization?

<p>Assessing the impact of incidents across departments. (D)</p> Signup and view all the answers

Which definition best describes an adverse incident?

<p>An unexpected event resulting in unintended harm, loss, or damage during patient care. (B)</p> Signup and view all the answers

When should an adverse incident be reported?

<p>Immediately, or not later than 24 hours if immediate reporting is impractical. (C)</p> Signup and view all the answers

Which of the following is a proper description of a clinical incident?

<p>An event or near miss that could lead to unexpected adverse outcomes during patient care. (C)</p> Signup and view all the answers

Which type of incident involves an event impacting equipment?

<p>Equipment Incident (A)</p> Signup and view all the answers

What characterizes a personal incident?

<p>Any incident affecting individuals not directly related to clinical care. (C)</p> Signup and view all the answers

Which definition is correct for a hazard?

<p>Anything that has the potential to cause harm. (D)</p> Signup and view all the answers

Which statement best describes a security incident?

<p>Any situation involving theft, loss, or damage to property. (D)</p> Signup and view all the answers

What is the nature of a vehicle incident within the reporting framework?

<p>An event involving any vehicle except for incidents categorized under security. (A)</p> Signup and view all the answers

Incidents should only be reported if they involve physical injuries to individuals.

<p>False (B)</p> Signup and view all the answers

Each approved policy must have a checklist developed for auditing its effectiveness.

<p>True (A)</p> Signup and view all the answers

To report an incident involving multiple persons, a single form is required for all individuals involved.

<p>False (B)</p> Signup and view all the answers

Patient satisfaction surveys can provide valuable data for improving healthcare systems.

<p>True (A)</p> Signup and view all the answers

Policy auditing can only detect incidents immediately after they occur.

<p>False (B)</p> Signup and view all the answers

Referencing alternative medical or other opinions is unnecessary for managing incidents.

<p>False (B)</p> Signup and view all the answers

Immediate assessment of the injured person is the first step in managing incidents.

<p>True (A)</p> Signup and view all the answers

Post discharge reporting is irrelevant for detecting events related to hospital treatment.

<p>False (B)</p> Signup and view all the answers

A Hospital Administrator may delay reporting an adverse incident for up to 48 hours after the incident occurs.

<p>False (B)</p> Signup and view all the answers

A personal incident can involve exposure to blood and body fluids in a healthcare setting.

<p>True (A)</p> Signup and view all the answers

A fire incident is defined as any incident involving fire or fire warning systems, regardless of its size.

<p>True (A)</p> Signup and view all the answers

The reporting of a clinical incident is only necessary if it results in severe harm to the patient.

<p>False (B)</p> Signup and view all the answers

All incidents involving theft or damage to personal property are classified as vehicle incidents.

<p>False (B)</p> Signup and view all the answers

An incident defined as a hazard is something that can cause harm.

<p>True (A)</p> Signup and view all the answers

Medication incidents are examples of clinical incidents and should be reported immediately.

<p>True (A)</p> Signup and view all the answers

A reporting policy suggests that incidents need to be reported only if they are unusually severe or unexpected.

<p>False (B)</p> Signup and view all the answers

The Incident/Accident Reporting policy only applies to permanent employees of the Ministry of Health.

<p>False (B)</p> Signup and view all the answers

An 'Incident Report File' must be maintained by the Hospital Administrator or their designee.

<p>True (A)</p> Signup and view all the answers

All incidents and accidents must be reported within 48 hours of their occurrence.

<p>False (B)</p> Signup and view all the answers

The policy encourages a person-centered approach to problem resolution.

<p>False (B)</p> Signup and view all the answers

Ministry of Health officials must be notified in writing of all incidents involving media issues.

<p>True (A)</p> Signup and view all the answers

The reporting of adverse incidents is discouraged to promote a culture of fear and blame.

<p>False (B)</p> Signup and view all the answers

Identifying trends in complaints and adverse incidents is one of the objectives of the Incident/Accident Reporting policy.

<p>True (A)</p> Signup and view all the answers

Only the Hospital Administrator is responsible for completing the incident reports.

<p>False (B)</p> Signup and view all the answers

Match the following incident reporting mechanisms with their descriptions:

<p>Medical Record Review = Assessment of patient records to find errors Post discharge reporting = Identifying events that emerge after patient discharge Policy auditing = Checking adherence to established hospital policies Patient satisfaction surveys = Collecting patient feedback on their care experience</p> Signup and view all the answers

Match the steps in incident management with their corresponding actions:

<p>Assessing the injured person = Determine the severity of injuries immediately Taking appropriate actions = Implement urgent treatment protocols Contacting the medical team = Engaging relevant healthcare professionals for assistance Referring for other opinions = Seeking additional medical insights as necessary</p> Signup and view all the answers

Match the types of incidents with their categories:

<p>Clinical incident = Errors related to patient treatment Vehicle incident = Events impacting transportation equipment Personal incident = Exposure to bodily fluids in healthcare Security incident = Events affecting the safety of individuals or property</p> Signup and view all the answers

Match the descriptions with their relevant reporting expectations:

<p>Incident Report Forms = Documents to report individual incidents Checklist for auditing = Tool for assessing policy compliance effectiveness Hospital Administrator's review = Oversight for analysis and action on incidents Formal complaints = Patient feedback indicating adverse experiences</p> Signup and view all the answers

Match the steps in incident identification with their methods:

<p>Incident reporting = Documenting occurrences directly by staff Policy auditing = Reviewing adherence to healthcare policies Post discharge reporting = Evaluating patient conditions after leaving the hospital Medical record review = Assessing records to identify potential errors</p> Signup and view all the answers

Match the incident types with their definitions:

<p>Hazard = A potential source of harm Fire incident = An event involving fire or heating systems Theft incident = Loss of personal property through unlawful actions Medication incident = Errors occurring in drug administration to patients</p> Signup and view all the answers

Match the responsibilities involved in incident management with the roles:

<p>Unit/section/department head = Complete and submit incident reports Hospital Administrator = Review and analyze incident reports Injured person = Assess immediate needs and seek treatment Reporting staff = Document occurrences using Incident Report Forms</p> Signup and view all the answers

Match the types of documentation related to incident reporting with their purposes:

<p>Incident Report File = Maintaining records for all reported incidents Checklist for auditing = Evaluating compliance and effectiveness of policies Patient satisfaction surveys = Gathering feedback for quality improvement Post discharge reports = Tracking issues arising after patient discharge</p> Signup and view all the answers

Match the type of incident with its correct definition:

<p>Clinical Incident = An event or near miss affecting a patient Equipment Incident = An event or near miss involving equipment Personal Incident = An incident affecting an individual unrelated to clinical treatment Fire Incident = Any incident involving fire or fire warning systems</p> Signup and view all the answers

Match the following aspects of the Incident/Accident Reporting policy with their corresponding descriptions:

<p>Purpose and Applicability = Ensures a transparent incident management system Policy Statements = Mandates timely reporting of incidents Incident Report File = Maintained by Hospital Administrator or designee Adverse Incident = An event that causes harm or potential harm</p> Signup and view all the answers

Match the report type with its reporting requirements:

<p>Adverse Incident = Report within 24 hours if immediate reporting is impractical Significant Incident = Report immediately Medication Incident = Includes prescribing and administration errors Vehicle Incident = Involves road traffic accidents excluding theft or vandalism</p> Signup and view all the answers

Match the following roles with their responsibilities in the Incident/Accident Reporting process:

<p>All Employees = Required to report incidents to supervisors Hospital Administrator = Responsible for maintaining incident report files Ministry of Health Officials = Must be informed of incidents involving media Supervisors = Oversee the reporting of adverse incidents</p> Signup and view all the answers

Match the term with its correct description:

<p>Adverse Incident = Unexpected harm arising during care Harm = Injury or disability unrelated to a patient's condition Risk = Chance of an event impacting expected outcomes Hazard = Anything that can cause harm</p> Signup and view all the answers

Match the responsibility with the corresponding role:

<p>Hospital Administrator = Ensure timely invitation of family members for incident meetings Clinician = Report clinical incidents involving patients Staff Member = Report any significant incident immediately Safety Officer = Oversee the completion of incident reports</p> Signup and view all the answers

Match the following approaches with their focus in incident management:

<p>System-centered approach = Focuses on the system rather than individual errors Person-centered approach = Encourages understanding individual behavior Continuous Improvement = Aims to identify opportunities for enhancing services Fair and Just Culture = Supports staff in reporting incidents without fear of blame</p> Signup and view all the answers

Match the following reporting requirements with their timelines:

<p>Incidents must be reported = Within 24 hours of occurrence Media-related incidents notification = In writing to Ministry of Health officials Incident report form submission = To respective supervisor or manager Review of incident reports = Regular audits by Hospital Administrator</p> Signup and view all the answers

Match the reporting timeframe with the incident type:

<p>Adverse Incident = Not later than 24 hours Clinical Incident = Immediately after occurrence Personal Incident = Report as soon as possible Fire Incident = Regardless of incident size, report immediately</p> Signup and view all the answers

Match the following types of incidents with their characteristics:

<p>Clinical Incident = May involve harm to patients Security Incident = Concerns safety and protection of individuals Hazard = Identified as a potential source of harm Medication Incident = Involves errors related to medication administration</p> Signup and view all the answers

Match the following incidents with an example:

<p>Violence Incident = Physical assault of a healthcare worker Security Incident = Theft of personal property Fire Incident = Activation of a fire warning system Equipment Incident = Malfunction of a medical device during use</p> Signup and view all the answers

Match the following examples of reporting errors with their potential impacts:

<p>Delaying incident reporting = Can obscure trends in patient safety Failure to maintain report files = Hinders accountability and transparency Not notifying officials of media incidents = Can lead to misinformation in the public Poor documentation of adverse incidents = Limits organizational learning and improvement</p> Signup and view all the answers

Match the component of an incident report with its significance:

<p>Description of Incident = Details the circumstances leading to the event Immediate Actions Taken = Shows response time and urgency of care Witness Statements = Provides additional perspectives on the incident Follow-up Actions Required = Ensures future prevention of similar incidents</p> Signup and view all the answers

Match the following concepts with their definitions:

<p>Adverse Incident = An unplanned event resulting in harm Incident Report Form = Official document for reporting incidents Continuous Improvement = Ongoing effort to enhance service quality Transparent Management System = Open procedures for addressing incidents</p> Signup and view all the answers

Match the reporting recommendation with its purpose:

<p>Immediate Reporting = Facilitates quick response and management of incidents Comprehensive Documentation = Ensures accuracy in incident analysis Family Involvement = Promotes transparency and trust in care Regular Auditing = Identifies trends and improves safety protocols</p> Signup and view all the answers

Match the following policies with their focus areas:

<p>Incident Reporting Policy = Supports a culture of transparency Workplace Safety Policy = Focuses on user safety within facilities Patient Care Improvement Policy = Aims to enhance quality of healthcare services Staff Support Policy = Encourages reporting without punishment</p> Signup and view all the answers

Match the following types of incidents with their appropriate definitions:

<p>Adverse Incident = An event that causes harm or injury to a patient Clinical Incident = An incident that directly affects a patient's clinical care Hazard = A potential danger that can cause harm Security Incident = An event that threatens the safety or security of the facility</p> Signup and view all the answers

Match the following reporting timelines with their corresponding policies:

<p>Incident must be reported = Within 48 hours of occurrence Adverse incident recording = Within 24 hours after identification Annual review deadline = 1/12/2025 Media involvement notification = In writing and immediately</p> Signup and view all the answers

Match the following incident types with their specific reporting requirements:

<p>Medication Incident = Should be reported immediately Vehicle Incident = Reported only if there are injuries Fire Incident = Requires notification regardless of size Personal Incident = Includes exposure to blood and body fluids</p> Signup and view all the answers

Match the following aspects of the policy with their emphasis:

<p>Incident reporting = Enhancing patient safety measures Policy auditing = Detecting trends in complaints Culture of reporting = Promoting a blame-free environment Patient feedback = Identifying unexpected events</p> Signup and view all the answers

Match the following responsibilities with the appropriate roles:

<p>Hospital Administrator = Maintains the Incident Report File Center Staff = Responsible for reporting incidents Policy Auditors = Ensure compliance with reporting procedures Ministry of Health = Notified for all incidents involving media</p> Signup and view all the answers

Match the types of incidents with their definitions:

<p>Adverse Incident = An event that results in harm to a patient Clinical Incident = An event that occurs in the clinical setting affecting patient care Personal Incident = An incident involving exposure to blood and body fluids Hazard = Something that has the potential to cause harm</p> Signup and view all the answers

Match the roles with their responsibilities in the Incident Reporting Policy:

<p>Hospital Administrator = Maintain an 'Incident Report File' Healthcare Staff = Report incidents within 48 hours Ministry of Health Officials = Receive written notifications of media-related incidents Patient Feedback = Identify trends for improving healthcare systems</p> Signup and view all the answers

Match the reporting timelines with their requirements:

<p>48 hours = Time limit for reporting all incidents 24 hours = Recommended time for reporting medication errors Immediately = Action required for severe adverse incidents Weekly = Frequency for reviewing reported incidents</p> Signup and view all the answers

Match the incident reporting procedures with their characteristics:

<p>Incident Report Form = Used for documenting details of incidents Audit Checklist = Developed for evaluating policy effectiveness Patient Satisfaction Surveys = Tools for collecting feedback on care Incident Categorization = Classifies incidents based on severity</p> Signup and view all the answers

Match the consequences of incident reporting with their effects:

<p>Promoting a blame culture = Hinders effective reporting Identifying trends = Helps in preventing future incidents Immediate assessment = First step in managing an incident Engagement in learning = Fosters continuous improvements in healthcare</p> Signup and view all the answers

Match the following terms related to incident reporting with their definitions:

<p>Incident Report = Form used to document unusual problems or incidents Adverse Incident = An event likely to lead to undesirable effects Clinical Incident = Any incident that affects patient care Hazard = Something that can cause harm</p> Signup and view all the answers

Match the following components of an incident reporting framework with their purposes:

<p>Documentation = Recording events to identify trends Assessment = Evaluating the severity of incidents Notification = Informing relevant authorities about incidents Analysis = Determining the underlying causes of incidents</p> Signup and view all the answers

Match the following reporting timelines with their required actions:

<p>48 hours = Timeframe to report all incidents Immediate = Action required for medication incidents Post discharge = Reporting events related to hospital treatment Delayed reporting = Up to 48 hours for certain incidents</p> Signup and view all the answers

Match the following types of incidents with their relevant characteristics:

<p>Security Incident = Involves unauthorized access or threats Vehicle Incident = Impacts equipment during transportation Personal Incident = May involve exposure to bodily fluids Fire Incident = Any incident related to fire or alarms</p> Signup and view all the answers

Match the following objectives of the Incident/Accident Reporting policy with their intended outcomes:

<p>Trend Identification = Recognizing patterns in complaints and incidents Patient Safety = Enhancing care by preventing adverse events Accountability = Assigning responsibility for incident management Culture of Reporting = Encouraging open communication about incidents</p> Signup and view all the answers

Which of the following statements best reflects the requirements for reporting incidents under the policy?

<p>All incidents should be reported within 48 hours, regardless of severity. (C)</p> Signup and view all the answers

What is the correct role of the Hospital Administrator in the incident reporting process?

<p>To maintain an 'Incident Report File' and oversee reporting compliance. (D)</p> Signup and view all the answers

Which scenario requires immediate reporting according to the Incident Reporting policy?

<p>A clinical incident arises that results in moderate harm to a patient. (B)</p> Signup and view all the answers

Which of the following is NOT a primary objective of the Incident/Accident Reporting policy?

<p>Promoting a culture of fear and blame among staff. (B)</p> Signup and view all the answers

What aspect characterizes the approach promoted by the Incident Reporting policy?

<p>A transparent and cooperative methodology aimed at overall improvement. (A)</p> Signup and view all the answers

What is the time frame for reporting all incidents and accidents as per the policy?

<p>Within 48 hours of occurrence (D)</p> Signup and view all the answers

Which of the following statements about the reporting of adverse incidents is true?

<p>The reporting of adverse incidents is encouraged to foster a culture of transparency. (B)</p> Signup and view all the answers

Which party is primarily responsible for maintaining an 'Incident Report File'?

<p>The Hospital Administrator or their designee (D)</p> Signup and view all the answers

What approach does the Incident/Accident Reporting policy promote for problem resolution?

<p>A person-centered approach (C)</p> Signup and view all the answers

Who must be notified in writing of all incidents involving media issues?

<p>The Ministry of Health officials (C)</p> Signup and view all the answers

What is the primary purpose of an incident report?

<p>To document any unusual problem that may lead to undesirable effects. (D)</p> Signup and view all the answers

Which of the following situations would require the completion of an incident report?

<p>An unexpected variation from established policies. (B)</p> Signup and view all the answers

What could be considered a consequence of failing to report an incident?

<p>Increased risk of the same issue occurring again. (A)</p> Signup and view all the answers

What type of information is most critical to include in an incident report?

<p>Details of the event that could lead to undesirable effects. (D)</p> Signup and view all the answers

In the context of incident reporting, which of the following statements is true?

<p>All variations from the norm should be documented regardless of their potential impact. (A)</p> Signup and view all the answers

An incident report is used solely for documenting physical injuries.

<p>False (B)</p> Signup and view all the answers

An adverse incident is only defined as a situation that results in severe harm to patients.

<p>False (B)</p> Signup and view all the answers

Ministry of Health officials must be notified of all incidents involving media issues verbally.

<p>False (B)</p> Signup and view all the answers

An 'Incident Report File' must be maintained by either the Hospital Administrator or their designee.

<p>True (A)</p> Signup and view all the answers

Policy auditing can detect incidents that occur at any time, not just immediately after they occur.

<p>True (A)</p> Signup and view all the answers

The Incident/Accident Reporting policy only requires notifications for severe incidents affecting patients.

<p>False (B)</p> Signup and view all the answers

Which sentinel event does NOT require reporting under the existing policy?

<p>An error in medication dispensing (A)</p> Signup and view all the answers

What type of analysis can help identify the root causes of incidents in healthcare settings?

<p>Cause and Effect Analysis Investigation Form (B)</p> Signup and view all the answers

Which of the following best describes the purpose of the Action Hierarchy as outlined in the documents?

<p>To categorize actions based on their strength in preventing reoccurrence (B)</p> Signup and view all the answers

Which category of sentinel event includes incidents of self-harm by staff?

<p>Staff Suicide or Self-harm incidents (D)</p> Signup and view all the answers

What is the primary focus of the electronic report forms mentioned in the documents?

<p>To track adverse incidents and establish corrective actions (D)</p> Signup and view all the answers

What is a sentinel event?

<p>A patient safety issue resulting in severe temporary or permanent harm. (A)</p> Signup and view all the answers

Which of the following defines 'Severe Temporary Harm'?

<p>Critical harm lasting less than four months without permanent effects. (C)</p> Signup and view all the answers

Which of the following is NOT considered an invasive procedure?

<p>Visual examination with no body access. (B)</p> Signup and view all the answers

What is the purpose of the corrective action plan following a sentinel event?

<p>To prevent the reoccurrence of similar events. (B)</p> Signup and view all the answers

Which statement accurately describes the 'Internal Notification Date'?

<p>The date when the event occurs within the facility. (A)</p> Signup and view all the answers

What does 'Measures of Effectiveness' refer to in the context of this policy?

<p>Data quantifying compliance and the impact of recommended changes. (C)</p> Signup and view all the answers

What criteria determine the applicability of this policy?

<p>Applicable to all healthcare staff and facilities regulated by MOH. (D)</p> Signup and view all the answers

Which of the following describes the role of Root Cause Analysis (RCA) in sentinel events?

<p>A process for analyzing underlying causes of events to improve outcomes. (C)</p> Signup and view all the answers

What should be ensured when a sentinel event involves multiple facilities within the same region?

<p>Quality and Patient Safety in the RHD shall facilitate the RCA review. (B)</p> Signup and view all the answers

What is required of the healthcare facility after a sentinel event is reported?

<p>To provide needed support to the staff involved as per the second victim program. (B)</p> Signup and view all the answers

How should lessons learned from sentinel events be disseminated?

<p>Through the Quality and Patient Safety departments to relevant facilities. (C)</p> Signup and view all the answers

When should the initial disclosure of a sentinel event to the patient occur?

<p>Immediately upon discovering the incident. (B)</p> Signup and view all the answers

What is a key performance measurement related to incident reporting time frames?

<p>Measuring compliance with 48 hours reporting to the MOH Portal. (B)</p> Signup and view all the answers

What type of support should be provided to staff involved in a sentinel event?

<p>Legal and psychological support as per the second victim program. (A)</p> Signup and view all the answers

Which statement best describes the role of the GD-QPS in case of sentinel events across different regions?

<p>They facilitate the RCA and team formation in coordination with relevant deputies. (B)</p> Signup and view all the answers

What happens to reports of lessons learned from sentinel events?

<p>They are disseminated regularly to the General Directorate of Hospitals Affairs. (D)</p> Signup and view all the answers

What is a responsibility of the healthcare facility once a sentinel event occurs?

<p>To secure the confidentiality and security of the reported event. (C)</p> Signup and view all the answers

What should the final disclosure process to the patient include?

<p>Completeness of the RCA by the treating team and coordination with hospital leadership. (D)</p> Signup and view all the answers

What characterizes a Sentinel Event in the context of incident reporting?

<p>Incidents that result in actual injury or death. (D)</p> Signup and view all the answers

Which statement best defines the role of the Most Responsible Physician (MRP)?

<p>The physician accountable for overall patient management during their hospital stay. (A)</p> Signup and view all the answers

What is the primary purpose of a Corrective Action Plan (CAP)?

<p>To identify and implement strategies to reduce the risk of similar incidents. (D)</p> Signup and view all the answers

Which of the following is NOT a typical member of the RCA team?

<p>Representatives from the IT department. (A)</p> Signup and view all the answers

Within what time frame must Sentinel Events be reported to the Ministry of Health?

<p>Within 48 hours after discovery. (D)</p> Signup and view all the answers

Which document serves as a structured retrospective analysis to identify root causes of an event?

<p>Root Cause Analysis (RCA). (D)</p> Signup and view all the answers

Which of these categories is essential for developing a Sentinel Events Policy in a healthcare facility?

<p>Reporting must be aligned with national sentinel event criteria. (B)</p> Signup and view all the answers

What method can contribute to the identification of Sentinel Events?

<p>Social media monitoring. (C)</p> Signup and view all the answers

What distinguishes the definition of a Safety Event Report (SER)?

<p>It includes any undesired incidents affecting patients or staff. (A)</p> Signup and view all the answers

Which role does the Regional Health Directorate (RHD) primarily serve in relation to Health care facilities?

<p>Overseeing the compliance to national healthcare regulations. (D)</p> Signup and view all the answers

What is the primary requirement for a health care facility after receiving a report of a sentinel event?

<p>They must respond to the GD-QPS within 24 working hours. (B)</p> Signup and view all the answers

Who should NOT be included in the RCA review committee?

<p>Any individual involved in the sentinel event. (B)</p> Signup and view all the answers

In the case of patient death as a result of a sentinel event, what is a critical action regarding the patient's medical record?

<p>It should be secured with controlled access to prevent modifications. (A)</p> Signup and view all the answers

What is the role of the general director of the health care facility when a sentinel event is reported?

<p>To activate the RCA review committee. (B)</p> Signup and view all the answers

Which statement correctly describes the rights of the RCA review committee?

<p>They have the right to interview individuals at all organizational levels. (A)</p> Signup and view all the answers

If the sentinel event does not result in patient death, how must the patient medical record be managed?

<p>The original is released while keeping a copy secured. (B)</p> Signup and view all the answers

What must be ensured regarding the devices involved in a sentinel event?

<p>They need to have controlled and secured access. (B)</p> Signup and view all the answers

What is a requirement for at least one member of the RCA review committee?

<p>They should have extensive knowledge in the RCA workflow process. (C)</p> Signup and view all the answers

What action should the GD-QPS take if the facility does not respond to the initial email notification?

<p>They will escalate the situation through their mechanism. (B)</p> Signup and view all the answers

Flashcards

Incident

An event that could cause negative consequences like media attention, legal action, or damage to the hospital's reputation.

Incident Reporting

The process of formally recording an incident for investigation and action.

Incident Report Forms

Hospital forms used to report incidents, ensuring information is collected consistently.

Medical Record Review

Reviewing patient records to identify potential incidents or areas for improvement.

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Post-discharge Reporting

Reporting events that occur after a patient is discharged from the hospital.

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Policy Auditing

Evaluating hospital policies to ensure they are effective and being followed.

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Patient Satisfaction/Complaints

Gathering feedback from patients through surveys and complaints to understand their experiences.

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Procedure for Managing Incidents

A series of steps taken to manage an incident, including assessment, treatment, and documentation.

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What is an Incident?

A situation that might result in negative consequences like media attention, legal action, or damage to the hospital's reputation.

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What is Incident Reporting?

The practice of officially recording incidents for investigation and action.

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What are Incident Report Forms?

Hospital forms used to report incidents consistently.

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Who is responsible for incident reporting?

All full-time and part-time employees, students, interns, voluntary workers, visitors, and contractors are required to report adverse incidents, risks, harm, or hazards associated with their work to their respective supervisor or manager.

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What is the purpose of a fair and just culture for incident reporting?

This policy promotes a fair and just culture where staff are supported in reporting adverse incidents.

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Why is it important for hospitals to track incidents?

Hospitals use reporting systems to track occurrences to see if there are patterns or recurring issues.

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How does a system-centered approach address incident reporting?

Hospitals aim to identify and address problems from a system-wide perspective rather than focusing on blaming individuals.

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What is the procedure for handling incidents involving media?

The hospital must inform authorities in writing about incidents involving media issues.

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Adverse Incident

An unwanted event that leads to harm, loss, or damage, often unexpected and not related to a patient's illness.

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Risk

The possibility that something will happen and cause harm, measured by the likelihood of occurrence and its potential impact.

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Harm

Injury, disease, disability, death, or suffering, especially if unexpected and not related to a patient's condition.

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Hazard

Anything that could cause harm, such as a faulty medical device or an unsafe work environment.

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Clinical Incident

A situation where a patient experiences or nearly experiences an unexpected negative outcome during their care.

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Equipment Incident

An event involving equipment that leads to or almost leads to an adverse outcome, potentially affecting a patient's care.

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Personal Incident

An incident involving a hospital employee or visitor, but not related to direct patient care.

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Fire Incident

Any event involving fire or fire alarms, even if it's a false alarm.

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System-centered Approach

Hospitals aim to address problems from a system-wide perspective rather than focusing on blaming individuals.

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Fair and Just Culture

This policy promotes a fair and just culture where staff are supported in reporting adverse incidents.

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What is an Incident Report Form?

A specific form used to document incidents and gather key information for investigation.

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Explain Medical Record Review.

The process of reviewing patient records to identify incidents or areas for improvement.

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What is Patient Satisfaction/Complaints?

Collecting feedback from patients about their experiences, through surveys or complaints, to understand areas for improvement.

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Step 1 in Incident Management.

Assessing the injured person or damaged property to determine the extent of harm and necessary actions.

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What is Step 2 in managing an Incident?

Taking appropriate measures to reduce further injury or damage, potentially involving medical intervention or other support.

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Who should you contact in case of patient errors?

Identifying the relevant medical team to evaluate the incident and determine the next steps.

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What is a fair and just culture for incident reporting?

A system where staff feel encouraged to report incidents without fear of blame, promoting an open culture for learning and improvement.

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What is Medical Record Review?

Reviewing patient records to identify potential incidents or areas for improvement. This looks for patterns or trends in care.

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What is step one in incident management?

To assess the injured person or damaged property to determine the extent of harm and necessary actions. This is the first step in managing an incident.

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What is a system-centered approach?

Hospitals aim to identify and address problems from a system-wide perspective rather than focusing on blaming individuals. This focuses on improving processes and procedures.

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What is step two in managing an incident?

Taking appropriate measures to reduce further injury or damage, potentially involving medical intervention or other support. This is the second step in managing an incident.

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Incident Report

A form used to document any unusual problems, incidents, variations, or situations that deviate from established policies and procedures. This includes situations that could potentially lead to undesirable effects.

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Fair & Just Culture

A system where staff are encouraged to report incidents without fear of blame, promoting an open culture for learning and improvement.

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Assessing the Injured Person

The first step in managing an incident, focusing on determining the extent of harm and identifying necessary actions.

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Reducing Further Harm

The second step in managing an incident, involves taking actions to prevent further harm and provide necessary support.

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Incident Documentation

The act of documenting an event that could potentially lead to undesirable outcomes or deviations from pre-established policies and procedures.

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Incident Management

A collection of steps taken to manage an incident, starting with assessing the situation and then taking action to prevent further harm.

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Sentinel Event

An unexpected patient safety event that results in death, permanent harm, or severe temporary harm, not related to the patient's natural illness.

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Event Occurrence Date

The date on which the sentinel event occurred.

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Internal Notification Date

The date when the sentinel event is reported within the healthcare facility.

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Severe Temporary Harm

A critical injury that is potentially life-threatening, lasting less than 4 months, requiring a higher level of care for an extended period, or requiring major surgery or procedures to resolve.

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Invasive Procedure

A procedure that involves deliberate entry into the body through an incision, puncture, or natural orifice, using instruments.

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Measures of Effectiveness

Data used to measure the effectiveness of the action plan in preventing future sentinel events.

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Root Cause Analysis (RCA)

A systematic investigation of a sentinel event to identify the root causes and develop corrective actions.

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Corrective Action Plan

Actions taken to prevent the reoccurrence of sentinel events.

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Just Culture

A policy that encourages reporting of errors without fear of punishment, promoting an open culture of learning and improvement.

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Dissemination of Lessons Learned

Sharing information about sentinel events and lessons learned to prevent future occurrences.

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Disclosure to Patient

The process of making information accessible to patients in understandable language, respecting patient autonomy and promoting informed decision-making.

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Second Victim Program

A program providing support to healthcare staff involved in sentinel events, offering resources like legal or psychological assistance.

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Performance Measurement

Regularly evaluating and measuring the implementation of patient safety initiatives to identify areas for improvement.

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Patient Satisfaction Surveys

Gathering feedback from patients to understand their experiences, identify issues, and improve patient satisfaction.

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RCA Team

A multidisciplinary team, including representatives from different departments, responsible for conducting a root cause analysis.

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Action Plan

A plan outlining the actions an organization will take to address the root causes identified in a root cause analysis, reducing the risk of similar events.

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Most Responsible Physician (MRP)

A physician primarily responsible for a patient's care and management during their hospital stay.

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Sentinel Event (SE)

An incident that significantly deviates from standard operations, potentially causing or having the potential to cause injury, loss of function, or death.

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Safety Event Report (SER) / Occurrence Variance Report (OVR)

A report documenting any undesired event that may affect patients, employees, or the facility, potentially involving actual injury or the risk of harm.

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Sentinel Events Policy

A policy requiring reporting of sentinel events within 48 hours of discovery to the Ministry of Health (MOH).

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Ministry of Health (MOH)

The Ministry of Health, responsible for overseeing health policies and standards.

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Sentinel Event Identification

The process of identifying potential sentinel events by reviewing different sources like safety reports, complaints, or medical reviews.

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GD-QPS Notification

When a serious, unexpected patient safety event occurs, the General Directorate of Quality and Patient Safety (GD-QPS) notifies the related facility to report the event on the MOH portal.

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Facility Response Time

The facility must respond to the GD-QPS notification within 24 working hours, if they don't, the GD-QPS activates an escalation process.

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General Director Notification

The facility's general director must be informed within 24 hours of discovering a sentinel event.

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RCA Review Initiation

The facility's general director or their designee starts the Root Cause Analysis (RCA) review.

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RCA Review Committee

The RCA review committee consists of 4-6 professionals from different areas, relevant to the event. The individuals involved in the event are excluded from the committee.

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RCA Interviews

The RCA review committee can interview anyone involved in the event or who has knowledge about it.

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RCA Team Expertise

At least one member of the RCA team has experience in RCA processes and methods.

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Patient Record Security (Death)

If the event resulted in patient death, the patient's medical record is secured with controlled access to prevent any modifications.

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Patient Record Security (Non-Death)

If the event didn't result in death but involved organ or limb loss, a copy of the patient's medical record is secured and the original released for ongoing care.

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Device Data Retrieval

The facility ensures controlled and secured access to the devices involved in the event and retrieves data related to the patient's care.

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Study Notes

Incident/Accident Reporting Policy

  • The Ministry of Health uses a system to ensure quality patient care.
  • This policy provides a method to report incidents involving patients, staff, visitors, equipment, or services.
  • It aims to improve overall care and promotes a culture of teamwork and transparency.
  • This policy is not a replacement for the Ministry of Public Service Disciplinary Manual.

Purpose and Applicability

  • Provide a safe working environment.
  • Support a culture of reporting adverse incidents fairly.
  • Establish a structured incident management system.
  • Transition from a person-centered to a system-centered approach to problem resolution.
  • Identify trends in complaints, claims, and adverse events.
  • Maximize opportunities for improvement.
  • Applies to all Ministry of Health employees, students, interns, and voluntary workers.

Policy Statements

  • All staff must report adverse incidents, risks, harms, or hazards to their supervisor immediately or within 24 hours if immediate action is not possible.
  • All incidents/accidents must be reported within 24 hours of occurrence.
  • Ministry of Health officials must be informed in writing of any incidents involving media.
  • Incident reports are maintained by a Hospital Administrator.
  • Family members and legal guardians of affected patients will be notified and involved in a meeting.
  • Radiological/laboratory involvement requires physician approval/countersignature.
  • Staff escort for injured visitors to ER (Emergency Room), and Charge Nurse/Dept Head completes the report.
  • Ward/Department heads complete reports if staff injury prevents completion.
  • Staff must follow the incident report policy for accurate report completion.
  • Damaged/involved equipment should be retained along with documentation of the exact condition at the time of the incident.
  • If equipment is part of a batch, check if the defect is due to faulty storage and potentially withdraw the entire batch.
  • Reports are reviewed, analyzed, and the gathered data is used for trend analysis. Review analysis considers hospital managers, Deputy Regional Health managers, Regional Health Managers, reporting to Health Service Directors.
  • Incident reports must be completed accurately, detailing facts and avoiding opinions.

Definitions

  • Adverse Incident: An event/circumstance during care leading to unintended harm, loss, or damage.
  • Risk: The chance of something happening, measured by consequence and likelihood.
  • Harm: Any injury (physical or psychological), disease, suffering, disability, or death, unexpected or not directly related to the patient's condition.
  • Hazard: Anything with the potential to cause harm.

Procedure

  • When to Report: Incidents should be reported immediately or within 24 hours.
  • What to Report: Clinical incidents (medication errors, medical device malfunctions), equipment incidents, personal incidents (exposure to hazards), violence, abuse, harassment, fire incidents, security incidents, vehicle incidents, incidents with publicity potential, radiologic/lab incidents, incidents involving media, and more.

How to Report

  • Utilize the hospital's incident report forms.
  • Multiple people/departments involved require separate forms for each person.
  • Incidents affecting multiple departments should be rated by each department based on their impact.
  • Incident identification methods include medical record reviews, post-discharge reporting, policy auditing, and patient feedback/complaints.

Procedure for Managing Incidents

  • Assess the injured individual and damaged property immediately to determine the extent of harm.
  • Implement appropriate treatment/actions to minimize injury.
  • For patient errors, consult with relevant medical teams for assessment and referral.
  • Inform the patient and/or their family of the incident and necessary treatment.
  • Address media involvement appropriately, and avoid releasing information prematurely.
  • Ensure reports are accurate and factual.
  • Record Management actions and preventative measures, and feed this information back to the unit/department.
  • Keep incident forms and any related materials (equipment, packaging, etc.) for further analysis.

Incident Review

  • Conduct incident reviews by aggregating reports to identify potential trends.
  • Analyze aggregate reviews for incident variables and details. These details include incident type, nature of harm, incident circumstances, causation, actions taken, and proposed solutions.

Frequency Analysis

  • Use frequency analysis to count the occurrences of selected incident-related variables, considering factors such as speciality, department, time period, incident type, nature of harm, environment, and causation.

Implementing and Monitoring Improvement Strategies

  • Learning from incidents, reviews, feedback, and comparisons with best practices are used to develop and implement improvement strategies.
  • Identify and implement strategies to improve patient safety and care quality.
  • Support staff through all processes and involve them in solutions.

Training

  • Training is crucial to ensure all staff are aware of their incident reporting duties, and to develop incident management skills.
  • Provide in-service training to address problems identified from incident reports.
  • Maintain detailed records of training sessions and updates.

Forms

  • Use the MOH Incident/Accident Report Form.

Responsibilities

  • Staff involved in incidents must complete incident reports, with multiple staff needing separate reports.
  • Hospital administrators, supported by hospital management and health officials, will review and analyze all incidents for frequency analysis and ongoing trend reporting to health service directors.
  • Regional health personnel submit quarterly incident reports to their respective Deputy Directors.
  • Organize and implement training to build staff incident reporting awareness and skill development.
  • Communicate with patients and families regarding incidents promptly and involve them in discussions or activities based on details about the incident occurrence.
  • Support staff through investigations, providing ongoing assistance and appropriate resources.
  • Avoid placing undue pressure on staff involved in an incident.

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Related Documents

Ministry of Health Incident/Accident Reporting Policy PDF 2009
Incident Reporting Policy PDF
Sentinel Events Root Cause Analysis PDF

Description

This quiz covers the Incident/Accident Reporting Policy utilized by the Ministry of Health. It emphasizes the importance of reporting incidents involving patients, staff, and equipment to enhance quality care and foster a culture of transparency. The policy encourages a systematic approach to management and improvement in services.

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