Download Critical Incidents

Section
Risk Management
Policy number
2-H
Topic
Critical Incidents
Last Review Date
06/19/16
Last Revision Date
07/03/13
CARF Standards 1.H.4.b.(5-6), 1.H.9-10
Purpose
1.
2.
3.
4.
5.
The purpose of the procedure is to provide staff with the information
required to adequately address issues surrounding critical incidents.
Critical incidents include the following:
a. Elopement: client ran or wandered away during a session
b. Injuries: staff, client, or others were injured during a session
c. Violence: client or others became dangerously aggressive during a session
d. Sexual Assault: client or others became sexually aggressive during a session.
e. Suicidal: client or others indicated high suicide risk indicators during a session or
phone call
f. Weapons: client or others possessed, threatened with, or used a weapon during a
session
g. Substance use: client or others used, possessed, or appeared under the influence of
alcohol/drugs during a session
h. Restraint: staff used physical restraint with client or other during a session, which is a
violation of agency policy
i.
Seclusion: staff used seclusion with client or other during a session, which is a violation
of agency policy
j.
Vehicle accident: staff had a car accident going to or returning from a client session
k. Infectious disease: staff was exposed to a communicable disease during a session
l.
Hazardous material: staff was exposed to hazardous material during a session
m. Abuse/neglect reporting: staff called abuse hotline to report abuse, neglect or
exploitation against a child or disabled or elderly adult
n. Foster parent report: staff called abuse hotline to report misconduct by a foster
parent against a child in custody
o. Potential legal liability: staff have information that may result in adverse action
against the agency or its staff
Staff are required to perform the following actions in response to critical incidents:
a. Session incidents (a-h above): Contact the Clinical Supervisor within 24 hours and turn
in a completed Incident Report within 1 week
b. Health & safety incidents (i-k above): turn in a completed Incident Report within 1
week
c. Abuse reporting (l-n above): Contact the Clinical Supervisor before calling abuse
hotline and turn in a completed Incident Report within 1 week
d. Other incidents (o above): Contact the Program Manager within 24 hours and turn in
a completed Incident Report within 1 week
Supervisory staff who receive a report of a critical incident conduct a debriefing and
training with the staff involved regarding possible actions that could have prevented the
incident and may be used to prevent future incidents. This discussion is documented in
the Follow-up section of the Incident Report. Staff with repeated incidents may be
required to complete additional training, participate in additional clinical supervision, or
be subject to disciplinary action.
All staff receive competency-based training at hire and annually regarding identification
and reporting of critical incidents. Proof of training is maintained in personnel file.
Prevention of critical incidents is provided through annual training of staff in the following:
Risk Management – Critical Incidents
a.
b.
6.
Personal safety plan for clients
Personal safety procedures for staff, including identification of unsafe environmental
factors
c. Violence prevention & intervention, including de-escalation strategies
d. Personal health, including infection prevention & control
An analysis of critical incident reports is included in the is included in the Annual Health &
Safety Report and includes the following elements:
a. Causes
b. Trends
c. Actions for improvement, including training needed for staff and strategies to
reduce/prevent future recurrences
d. Results of the previous performance improvement plan
e. Compliance with internal & external reporting requirements
Risk Management – Critical Incidents
1.H.4.b.(5)
1.H.4.b.(6)
1.H.9.a
1.H.9.b
1.H.9.c
1.H.9.d
1.H.9.e
1.H.9.f.(3)
1.H.9.f.(4)
1.H.9.f.(5)
Personnel receive documented competency-based training in identification
of critical incidents
Personnel receive documented competency-based training in reporting of
critical incidents
The organization has written procedures regarding critical incidents that
include prevention
The organization has written procedures regarding critical incidents that
include reporting
The organization has written procedures regarding critical incidents that
include documentation
Critical Incidents,
Staff Training
Critical incidents,
Staff Training
Critical incidents
The organization has written procedures regarding critical incidents that
include remedial action
The organization has written procedures regarding critical incidents that
include timely debriefings conducted following critical incidents
The organization has written procedures regarding critical incidents that
include use of restraint
The organization has written procedures regarding critical incidents that
include incidents involving injuries
The organization has written procedures regarding critical incidents that
include communicable disease
Critical incidents
1.H.9.f.(6)
The organization has written procedures regarding critical incidents that
include infection control
1.H.9.f.(7)
The organization has written procedures regarding critical incidents that
include aggression or violence
1.H.9.f.(8)
The organization has written procedures regarding critical incidents that
include unauthorized use or possession of weapons
1.H.9.f.(9)
The organization has written procedures regarding critical incidents that
include wandering
The organization has written procedures regarding critical incidents that
include elopement
The organization has written procedures regarding critical incidents that
include vehicular accidents
The organization has written procedures regarding critical incidents that
include biohazardous accidents
The organization has written procedures regarding critical incidents that
include unauthorized use or possession of legal or illegal substances
1.H.9.f.(10)
1.H.9.f.(11)
1.H.9.f.(12)
1.H.9.f.(13)
1.H.9.f.(14)
1.H.9.f.(15)
1.H.9.f.(16)
1.H.9.f.(17)
1.H.9.f.(18)
1.H.10.a
1.H.10.b.(1)
The organization has written procedures regarding critical incidents that
include abuse
The organization has written procedures regarding critical incidents that
include neglect
The organization has written procedures regarding critical incidents that
include suicide or attempted suicide
The organization has written procedures regarding critical incidents that
include sexual assault
The organization has written procedures regarding critical incidents that
include other sentinel events
A written analysis of all critical incidents is provided to or conducted by the
leadership at least annually
A written analysis of all critical incidents is provided to or conducted by the
Critical incidents
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Infection Prevention
& Control
Critical incidents,
Infection Prevention
& Control
Critical incidents,
Clinical
Emergencies
Critical incidents,
Substance Use &
Weapons
Critical incidents
Critical incidents
Critical incidents
Critical incidents,
Hazardous materials
Critical incidents,
Substance Use &
Weapons
Critical incidents
Critical incidents
Critical incidents,
Clinical
Emergencies
Critical Incidents
Critical incidents
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Risk Management – Critical Incidents
1.H.10.b.(2)
1.H.10.b.(3)
1.H.10.b.(4)
1.H.10.b.(5)
1.H.10.b.(6)
1.H.10.b.(7)
1.H.10.b.(8)
leadership that includes causes
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes trends
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes actions for improvement
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes results of performance improvement plans
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes necessary education and training of personnel
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes prevention of recurrence
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes internal reporting requirements
A written analysis of all critical incidents is provided to or conducted by the
leadership that includes external reporting requirements
Critical incidents
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Risk Management – Critical Incidents