Effective Date: 
Fri, 08/01/2008
Fri, 02/16/2018
Fri, 02/16/2018

As part of our mission to provide quality care and a safe place for students, staff and visitors,we monitor incidents that could result in harm to anyone working or visiting Counseling and Psychological Services (CAPS). An incident report is created anytime there is an unexpected occurrence involving patient, staff or visitors.  In addition, incident reports are created for adverse events such as actual breaches in care, administrative procedures or other events resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service. Any process variation for which a recurrence carries a significant chance of a serious adverse outcome or events that could have resulted in an adverse event should be reported as an incident report. The online reporting system, RL Solutions, is to be used for the purpose of quality assurance monitoring and continuous quality improvement. The Opportunity for Improvement form will be used to identify potential system problems before they compromise care or cause harm and improve and revise policies and procedures as needed.

Examples of events which would trigger an Incident Report in RL Solutions include the following:

  • Dissatisfied or angry patient resulting in a request for transfer of care, refusal to return for evaluation or treatment or requesting to speak with a supervisor/manager.
  • Completed suicide or serious attempt resulting in significant injury.
  • Activation of emergency procedures (resuscitation, 911 emergency calls, use of panic button)
  • Injury to patients/visitors (Fainting, fall, unsafe situation)
  • Patient care concern (medication error, incorrect test/procedure, triage, patient flow, delayed or incorrect diagnosis, phone call)
  • Possible procedural error
  • Quality of care issue raised by patient
  • Quality of care issue raised by staff member
  • System or process needing improvement
  • Laboratory safety issue
  • Child abuse or elder/dependent abuse report

Any staff member can enter an incident in RL Solutions.  All incident reports are reviewed by the CAPS Director and Senior Associate Director as indicated. The incident reports are distributed to appropriate managers for review and investigation, if indicated and reported back to the CAPS Director with recommendations to prevent future recurrences if the event was related to quality of care or safety issues that could potentially benefit from additional preventive measures. Individual staff members involved in incidents are provided specific feedback as appropriate. The incident report is not to be filed in patient’s mental health record. To ensure confidentiality, students should be identified in RL Solution reports only through the Student ID# and initials.  Date of Birth, which is a required field, should be made up.  The correct age can be manually entered to override the default.

The Opportunity for Improvement form can be used when there is a minor error that results in no student or staff harm.  Examples would be PHI left out in a locked office that only staff have access to, inadvertent documentation in the wrong student chart that is noticed and corrected immediately, or inadvertent access to a student chart without a clear reason to do so. These forms are reviewed internally by CAPS Management with feedback given to staff member as indicated.  The form is then submitted to the Medical Director for aggregation and reporting out to the SHS Quality Management Committee.

In an effort to ensure adequacy of evaluation and consideration of the least restrictive measures, when students are hospitalized from CAPS either voluntarily or involuntarily a hospital transfer form  is completed by the clinician or management team member involved and reviewed by the CAPS management team within one week of the hospitalization.  Reasons for hospitalization and 5150 documentation (if applicable) are reviewed. If indicated, the involved clinician is interviewed.   A summary of these situations is created by the SHS Quality Management Committee. The summary only includes number of transfers and whether the transfers were judged to be appropriate. No PHI or identifying information is communicated.

Risk management is performed by review of Occurrence Reports at least quarterly, sooner if needed for specific occurrences by the Quality Management Committee. These reports are used to identify generically high risk situations such as hospital transfers or to call the committee’s attention to possible quality of care issues, patient complaints, or environmental safety issues. The committee is charged with evaluating the need for further action based on review of the report and related documentation, and communicating that evaluation to the appropriate manager