Incident Reporting, Investigation, and Adverse Events
Requires staff to report every incident (a fall, medication error, injury, equipment failure, unexpected death, missed visit that caused harm, allegation against staff, or anything else that harmed or could have harmed a patient) to a supervisor at once and in writing within 24 hours, sets out which incidents must also go to the Health Care Personnel Registry, the county department of social services or law enforcement, and how incidents are investigated and fed into the quality program.
About this policy
- Policy number
- NC-HH-QA-03
- Version
- 1.0
- Main rule
- 42 CFR §484.65(c)
- Library
- North Carolina home health · 57 policies
- Category
- Quality
- Sections
- 17
In short
- Make the patient safe first. Call 911 if needed, then call the supervising nurse or on-call nurse at once.
- Do not clean up or throw away anything related to the incident unless safety requires it. Take broken equipment out of use and label it.
- Complete the incident report within 24 hours (Agency standard), and before the end of your shift if the incident is an allegation against staff.
- In the visit note, write only the facts: what happened, what you saw and what you did. Do not mention the incident report or blame anyone.
- Allegations against staff go to the Health Care Personnel Registry within 24 hours; suspected abuse of a disabled adult goes to the county department of social services.
- No one is disciplined for reporting an incident in good faith.
What's inside
17 sections. The full text comes with the One-time Policy Pack.
- Terms of Reference
- 1. Purpose
- 2. Scope
- 3. Definitions
- 4. Policy Statement (42 CFR §484.65(c)(2); 42 CFR §484.50(e))
- 5. What to Do First
- 6. Written Report
- 7. Notifications
- 8. Investigation
- 9. Learning from Incidents
- 10. Responsibilities
- 11. Records and Compliance Monitoring
- 12. Staff Training
- 13. References
- 14. Related Policies and Forms
- 15. Approval
- 16. Revision History
An inspector may ask
- Show me your incident reports for the last three months and what you did about each one.
- An aide finds a patient with a bruise no one can explain. What happens next, and by when?
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