1. Incident reporting Policy #C:2-075.1 CHAP CII.7I

2. purpose • To define the reporting, follow-up, and feedback process for incidents involving patients and Ambercare personnel

3. policy • Ambercare will maintain a process for generating incident reports and follow-up corrective action, if applicable. • To facilitate early detection of problems or compensable events • To establish a foundation for early investigation of all potentially serious events • To develop a database for long-range problem detection analysis and correction • To enable cross-reference with other risk detection systems • To investigate and respond to serious adverse events, in accordance with accrediting bodies standards

4. What constitutes an adverse event? • Provision of care errors • Unusual occurrences • Vehicular crashes • Others types of accidents and injury • Safety hazards Serious Adverse events include: • Unexpected death not resulting from the client’s medical condition • Loss of body part • Permanent or partial loss of body function • Blindness

5. What Surveyors are looking for….. • Evidence that Ambercare monitors and reports information related to adverse events • Reports document data on adverse events that predispose the organization to real or potential liability. • A system is in place for monitoring and reporting information related to adverse events that endanger the health and safety of clients and/or employees.

6. adverse events that predispose ambercare to real or potential liability – Process for reporting • Data must be collected within 30 days of event • Data is analyzed within 60 days of the event to determine underlying factors leading to the adverse event • Performance Improvement processes, as applicable, include evidence of organizational changes subsequent to an adverse event

7. Process when an incident occurs: • Immediate notification of supervisor • Follow-up with the patient and family/caregiver, and/or patient’s physician, if indicated by your supervisor or designee • Maintaining confidentiality of the information. The report is for INTERNAL use ONLY and is NOT available to physician or other agents outside Ambercare • Completion of incident report within 24 hours of incident.