II.J INCIDENT POLICY *

Effective Date: 
Fri, 08/01/2008
Reviewed: 
Fri, 07/02/2021
Revised: 
Fri, 07/02/2021
Policy: 

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 deviation 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 Datix, is to be used to document incidents for the purpose of quality assurance monitoring and continuous quality improvement.

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

  • Dissatisfied or angry patient requesting to speak with a supervisor/manager due to care resulting in harm or potential harm.
  • Completed suicide or serious attempt resulting in significant injury.
  • Activation of emergency procedures (5150's and voluntary hospitalizations, resuscitation, 911 emergency calls, use of panic button)
  • Injury to patients/visitors (Fainting, fall, unsafe situation)
  • Possible procedural error
  • Quality of care issue raised by patient
  • Quality of care issue raised by staff member
  • Child abuse or elder/dependent abuse report
  • Tarasoff situation
  • PHI and confidentiality breaches

Any staff member can enter an incident in RL Datix.  All incident reports are reviewed by the CAPS Director and/or Senior Associate Director as indicated. The incident reports are distributed to appropriate managers for review and investigation, if indicated. Incidents are 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 Datix 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.

Minor errors that result in no student or staff harm, such as 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 should be entered into the RL Datix system. The information 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, this information is entered into the RL Datix system 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.