Incident Reporting, Internal Investigation and Learning From Adverse Events
Sets out how staff report incidents inside the Agency, how each incident is triaged, screened for external reporting and investigated, and how the causes are analyzed and turned into preventive actions with feedback and learning across the Agency, as 42 CFR §418.58 requires.
About this policy
- Policy number
- DC-HSP-QA-02
- Version
- 1.0
- Main rule
- 42 CFR §418.58(a)(2), (c)(2)
- Library
- Washington, DC hospice · 60 policies
- Category
- Quality
- Sections
- 18
In short
- If something goes wrong, make the patient safe first and call 911 if needed.
- Tell the clinical manager or on-call nurse at once.
- If you suspect abuse or neglect, report it to APS or CFSA yourself right away as well.
- Fill in an incident report before the end of your shift. Write only the facts.
- Do not mention the incident report in the patient’s record.
- Reporting is for learning, not blame. No one is disciplined for reporting in good faith.
What's inside
18 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 §418.58(a)(2), (c)(2))
- 5. What Must Be Reported
- 6. Reporting Steps
- 7. Triage and External Reporting Screen
- 8. Investigation and Analysis
- 9. Telling the Patient and Family
- 10. Trending, Feedback and Learning
- 11. Responsibilities
- 12. Records and Compliance Monitoring
- 13. Staff Training
- 14. References
- 15. Related Policies and Forms
- 16. Approval
- 17. Revision History
An inspector may ask
- What do staff do when a patient falls or a medication error happens?
- Show me the incident reports for the last quarter and what you learned from them.
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