Ri 24 Incident Reports

RI 24
CRAIG HOSPITAL
POLICY/PROCEDURE
Approved: DD 11/06; SC, CIC, MEC, P&P Effective Date: 04/84
1/07; CC, P&P 6/07; 05/10; DD, MEC 09/11
P&P 10/11, 09/12
Attachments: Revised Date: 06/03, 3/05; 06/05;
A Incident Flow Chart 02/06; 12/06; 6/07,
05/10, 09/11, 09/12
Forms: Reviewed Date: 03/04
RI24F – Incident Report Form
PR12F – Disclosure Tracking Log Form
SUBJECT: INCIDENT REPORTS AND REPORTING TO THE

COLORADO DEPARTMENT OF HEALTH
RATIONALE: To provide a reporting system for occurrences which are

hazardous or potentially hazardous to patients, employees or
visitors at Craig Hospital, and to promote a safe environment
and system of care. To maintain a log of patient complaints for
analyses and trending. To report incidents as required by law to
the Colorado Department of Public Health and Environment
(CDPHE) Health Facilities and Emergency Services Division
(HFEMSD).
SCOPE: All Staff
POLICY:
I. Criteria for Completion of Incident Reports
A. Any occurrence that threatens the safety or well-being of patients or
visitors, or which results in an injury to patients or visitors, must be
reported on Incident Report Form (RI24F). Such incidents may involve falls,
Code Blue, medications, lab, medical imaging, elopement,
equipment/device, safety, privacy and other/miscellaneous.
B. Any “near miss”, an event that would have constituted an unintended event
in the system of care with potentially negative consequences to the patient,
but which was intercepted at the point of patient care service before it
actually reached the patient.
C. Any significant deviation from policies and procedures or the normal
routine of the hospital that could adversely affect quality of patient care.
D. Any patient complaint that warranted follow-up by a department director
will be entered into the incident report database. Unresolved complaints
are forwarded to the patient representative or hospital administration per
policy RI 26 Patient Concerns or Complaints.
II. Certain incidents are required by law to be reported to the CDPHE/HFEMSD
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RI 24
within one business day. These incidents as defined below will be immediately
reported to the Vice President of Clinical Services or Vice President of Patient
Care Services to complete the report to the CDPHE/HFEMSD.
III. Any employee that has concerns about the safety or quality of care provided
a patient in the hospital may report these concerns to the Joint Commission (1-
800-994-6610), the CDPHE, or other agencies. Hospital employees have the
right to speak out on behalf of a patient’s safety without fear of disciplinary
action, retaliation, or loss of employment.
PROCEDURE:
I. Completion of the Incident Report
A. Staff member observing the incident/near miss will promptly complete all
information on the electronic Incident Report Form (RI24Ffound on the
“Forms” section on the Craig Intranet site within 24 hours (unless immediate
notification is required. (see II). The form will be submitted to administration
when the staff members clicks the submit button.
1. If a patient is involved, the physician and nurse are notified as
appropriate and the physician’s name is so indicated on the form.
2. Check the incident or near miss box and then check appropriate
category of event. If the incident or near miss type is not listed, report
as “other” and describe the type of incident/near miss in the “other”
category.
3. Provide a brief description of the incident, near miss or patient
complaint. Be factual on what is reported. Do not include personal
opinions, feelings or suspicions. Do not place blame.
4. Complete the summary of medical condition/outcome, rating the
patient’s condition following the incident on the severity scale.
5. For patient complaints, summarize the follow-up activity under the
outcome section.
B. The physician, or his/her designee, informs the patient, or when appropriate,

the patient’s family, about the outcomes of care, including unanticipated
outcomes, as soon as reasonably possible.
II. In order to efficiently report specific occurrences (incidents) and data as required
by regulations of the CDPHE, all hospital departments and staff need to
communicate to the Vice President of Clinical Services or Vice President of Patient
Care Services immediately, and submit an electronic Incident Report (Form
RI24F).
A. The following occurrences are reportable to the CDPHE/HFEMSD:
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RI 24
1. Any occurrence that results in the death of a patient or resident of the
facility and is required to be reported to the coroner as arising from an
unexplained cause or under suspicious circumstances;
2. Any occurrence that results in any of the following serious injuries to a

patient or resident:
a. Brain or spinal cord injuries;

b. Life-threatening complications of anesthesia or life-threatening
transfusion errors or reactions;
c. Second or third degree burns involving 20% or more of the body
surface area of an adult patient or resident or 15% or more of the
body surface area of a child patient or resident;
3. Missing Person: Any time that a resident or patient of the facility cannot
be located following a search of the facility, the facility grounds, and the
area surrounding the facility and there are circumstances that place the
resident’s health, safety, or welfare at risk or, regardless of whether such
circumstances exist, the patient or resident has been missing for eight
hours;
4. Any occurrence involving physical, sexual, or verbal abuse of a patient

or resident by another patient, resident, or employee of the facility or a
visitor to the facility; If the abuse meets the occurrence standard, it must
also be reported to the police, also see RI 35 Victims of Abuse and
Neglect for more specific procedures in this area;
5. Any occurrence involving neglect of patient or resident, also see RI 35

Victims of Abuse and Neglect for more specific procedures in this area;
6. Any occurrence involving misappropriation of a patient’s or resident’s

property. For purposes of this policy, “misappropriation of a patient’s or
resident’s property” means a pattern of or deliberately misplacing,
exploiting, or wrongfully using, either temporarily or permanently, a
patient’s or resident’s belongings or money without the patient’s or
resident’s consent, also see RI 35 Victims of Abuse and Neglect for
more specific procedures in this area;
7. Any occurrence in which drugs intended for use by patients or residents

are diverted to use by other persons;
8. Any occurrence involving the malfunction or intentional or accidental

misuse of patient or resident care equipment that occurs during
treatment or diagnosis of a patient or resident and that significantly
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RI 24
adversely affects or, if not averted, would have significantly adversely
affected a patient or resident of the facility.
B. The Vice President of Clinical Services or Vice President of Patient Care

Services or their designee is responsible for reporting to the
CDPHE/HFEMSD Internet Portal www.cohfd-egov.com all above
occurrences by the next business day after the occurrence or after the
facility becomes aware of the occurrence.
C. If the internet portal is not available, the CDPHE/HFEMSD occurrence

reporting line 303-692-2900 may be used. The occurrence report would
then need to be submitted by internet once available.
III. Any report to the CDPHE/HFEMSD, law enforcement, community agencies,

programs/or individuals will be recorded in the Disclosure Tracking Log Form
(PR12F) and follow the procedures in policy PR 12 Release of Health Information
that does not require a Patient Authorization – State and Federal Laws. A copy of
the Disclosure Form will be sent to Health Information Management Department.
IV. Incident Report Data Base
A. Access to the incident report/near miss data base will be provided to

directors, designated supervisors and administrative personnel.
B. Data will be entered into the incident database by Administration or
Administrative Assistant Personnel.
C. Administration or Administration Assistant will forward the form and
associated number from the database to the Department
Director/Supervisor.
D. The Department Director/Supervisor will complete necessary follow-up and
enter a summary in the outcome section of the database. They will also
complete any follow-up screens as needed.
E. Patient identifiers are removed from the Incident Report Database at
6 months.
F. Monthly, quarterly and annual summary reports of the incident categories
will be provided and periodically reviewed in the Safety Committee, Nurse
Practice Council (Cor 0) Patient Experience Committee (patient complaints)
and Quality Council for trends and opportunities for improvement
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Incident/Near Miss Occurs
RI 24
Electronic incident report completed by

staff within 24 hours; MD notified as Immediate notification of supervisor
appropriate if patient is involved if incident/med error results in:
• Unexplained death
• brain injury, SCI, life-threatening
complications of anesthesia or
transfusion errors, second or
third degree burns to 20% or
more of body
Physician (or his/her designee) informs • elopement over 8 hours
patient (or patient’s family when • incidents of suspected violence,
appropriate) about significant, abuse or neglect
unanticipated outcomes of care • misappropriation of patient’s
property;
• drug diversion; or adverse
outcome from equipment
involved.
Incident entered into incident report

database and forwarded to department
director/supervisor involved. Pt. name is
removed from database after 6 months.
Supervisor notifies VP of Clinical

Services and VP of Patient Care
Services for CDPHE reports
Supervisor/director completes follow-up
in incident database. Notifies any other
departments involved.
CQI
Monthly, quarterly and annual
summaries of trends and opportunities 5 of 5

Ri 24 Incident Reports

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RI 24

SUBJECT: INCIDENT REPORTS AND REPORTING TO THE

RATIONALE: To provide a reporting system for occurrences which are

SCOPE: All Staff

I. Completion of the Incident Report

B. The physician, or his/her designee, informs the patient, or when appropriate,

A. The following occurrences are reportable to the CDPHE/HFEMSD:

2. Any occurrence that results in any of the following serious injuries to a

a. Brain or spinal cord injuries;

4. Any occurrence involving physical, sexual, or verbal abuse of a patient

5. Any occurrence involving neglect of patient or resident, also see RI 35

6. Any occurrence involving misappropriation of a patient’s or resident’s

7. Any occurrence in which drugs intended for use by patients or residents

8. Any occurrence involving the malfunction or intentional or accidental

B. The Vice President of Clinical Services or Vice President of Patient Care

C. If the internet portal is not available, the CDPHE/HFEMSD occurrence

III. Any report to the CDPHE/HFEMSD, law enforcement, community agencies,

IV. Incident Report Data Base

A. Access to the incident report/near miss data base will be provided to

Electronic incident report completed by

Incident entered into incident report

Supervisor notifies VP of Clinical

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