REVISED: 01-96, 02-97, 10-98, 11-99, 08-00, 06-01, 06-02, 1-03, 5-03

I. Purpose

To assure that all incidents not consistent with the routine operations of the hospital or the routine care of a particular patient are reported to the quality management department so that immediate attention and responses can be given to individual occurrences. Statistics can then be derived from the collective number of incidents reported and will serve as a basis for adverse patient trends, patient safety issues, or other risks and hazards to be identified, and risk reduction programs implemented.

In order to promote a culture that promotes patient safety, the hospital’s Incident Reporting Policy is based upon a foundation of nonpunitive approach to incident/occurrence reporting. The hospital leadership will encourage open and honest reporting of injuries and hazards to patients, visitors and staff, this process will be nonpunitive in nature for all persons reporting incidents throughout the organization. Incidence/occurrence investigations will be viewed as an opportunity for education/process improvement, and will focus on processes and systems, rather than human error.

Disciplinary action will be limited to only those employees who engage in willful or malicious misconduct, or those occurrences in which the employee failed to report an incident or hazard to patients in a timely manner.

II. Responsibility

A. All hospital employees, medical staff members, volunteers, and contract service members will participate in the hospital-wide incident reporting program. All incidents such as those listed as follows will be reported to the department of quality management:

1. Incidents involving inconsistencies with written hospital policies and procedures—informed consent, bedrails, patient