Critical Incidents
Health and human service organizations must report critical incidents to various state and/or federal agencies. Accreditation Now provides a module, the Accreditation Now Critical Incident Reporting System, which can be used to gather, store and summarize information regarding critical incidents. This reporting system can be utilized as a performance improvement indicator to track and trend critical incidents and create corrective action plans.
External Authorities
Organizations are required to adhere to legal requirements and regulations imposed by various external authorities. Authorities may include local or federal jurisdictions, licensing agencies, protection and advocacy agencies, funding sources, etc. The organization will follow the laws, rules and regulations required by the governing authorities as to records management and reporting of critical incidents. This may include the length of storage timelines and whether or not reports are to be filed in the records of persons served. The terminology of critical incidents may vary based on differing authorities.
Defining Critical Incidents
Critical incidents shall be defined to include any situation, action, or result of an action that is not consistent with the routine care of a person served, routine services provided by the organization, the routine operation of the organization, or the safety and security of environments in which services are provided. Critical incidents are also known as sentinel events, significant adverse events, or untoward events.
A critical incident policy should provide prompt and complete responses (1) to all persons served, staff members, and visitors’ needs in situations containing risk of injury; (2) to call attention to physical situations that need to be investigated or resolved to ensure a safe environment for patients, staff members, and visitors; (3) to determine issues that can be addressed for enhancement or improvement through management and planning; and (4) to manage risk of situations with potential liability for the organization.
Incidents of a serious nature that compromise the health and safety of persons served by a facility, its staff members, and visitors, should be documented and reviewed for the purpose of decreasing the likelihood of similar future incidents.
It should be the policy of all facilities that all situations, behaviors, and/or actions meeting the criteria for a reportable incident are documented and forwarded to the appropriate staff for further investigation and management, as per the procedures contained in each facility’s policy.
The specific events or incidents requiring preventive action, documentation, investigation, and corrective action will vary by program and patient characteristics. Such significant incidents or adverse events might include items from the list below. Note that even if an organization does not identify as engaging in seclusion or restraint activities, it must still include seclusion and restraint in its procedures for critical incidents.
Critical Incident Identification
- Injury or potential injury to a patient, visitor or staff member on your facility’s property or at an event sponsored by your facility
- Harm to family members or others from ingesting a patient’s medication
- Assaultive behavior or violence of any kind
- A vehicular accident in the performance of duties
- Seclusion or restraint of any person served, employee or visitor
- Any event that may have potential liability for your facility
- Suicide or attempted suicide
- Any other death that is drug-related, either to methadone or buprenorphine, or to any other drug; unexpected or suspicious deaths
- Any treatment-context death that raises individual, family, community or public concern
- Medical emergencies
- Medication errors
- Medication diversion
- Alleged physical, psychological, or sexual abuse
- Harassment or abuse of patients by staff
- Alleged neglect or abuse
- Self-abuse by a person served
- Alleged exploitation and/or harassment
- Alleged criminal activity
- Physician’s order errors
- Fires, natural disasters, bomb threats, and power failures
- Property damage/theft including facility property and/or personal property
- Incidents that have the potential for public access to information that may discredit your facility or compromise confidentiality
- Unauthorized use or possession of licit or illicit substances
- Selling unauthorized drugs on the premises
- Other undefined incidents that may include any situation, action, or result of an action that is not consistent with the routine care or services provided by the organization, the routine operation of the organization, or the safety and security of the organization’s environments
- Additional risks not identified here
Responsibility for the reporting and management of critical incidents
The Governing Body is the legal entity charged with the responsibility of health and safety management for the organization and within this role ensures that critical incident issues that affect the overall stability and continuing operation of the organization are being reported, reviewed, and managed within the overall structure of the organization.
The Critical Incident Officer is responsible for overall organizational oversight in the area of critical incident reporting and management and reviews all incidents by investigating and determining causes and trends, determining legal liability and insurance issues, and recommending policy and procedure changes based on the comprehensive reviews.
The Critical Incident Officer is responsible for the day-to-day oversight and functioning of the critical incident reporting system. Specific responsibilities include interviewing persons involved in the incidents, or who were witnesses to the incidents, to assist in developing conclusions and recommendations. The Critical Incident Officer should also provide and manage information regarding outside legal entities should an incident require such action. He/she should act as the point of contact for all supervisory personnel when a critical incident occurs within the organization. Additionally, the Critical Incident Officer advises the governing body about incidents of a severe nature that acutely threaten the therapeutic milieu of the organization and result in death, serious injury, alleged abuse, neglect, or exploitation of a patient, staff member, or visitor.
The Critical Incident Officer is responsible for serving as the organization’s point of contact for all critical incidents involving employees. Responsibilities in this area include serving as the liaison with the employee and outside entities in areas such as health insurance, worker’s compensation, and return-to-work issues and ensuring that all legal and regulatory requirements are being addressed in the area of employment practices and staff involvement in a critical incident.
The Critical Incident Officer role, as the overall coordinator of the facilities’ health and safety program, is responsible for any immediate response to a critical incident by ensuring that all health and safety policies and procedures are followed immediately after a critical incident has occurred. Any facility staff member is responsible for promptly reporting any incident that fits within the reporting guidelines for a critical incident. To support this process, staff members are expected to be knowledgeable about all organizational policies, procedures, and practices in the area of critical incident reporting.
PROTOCOL FOR HANDLING A CRITICAL INCIDENT
The protocol’s first action should be to manage the incident according to all health and safety policies, procedures and plans. There are certain events that require local authorities to be notified within 15 minutes of the discovery of the event. These events include, but may not be limited to (a) the death of anyone on the organization’s property by any means, (b) physical or sexual assaults involving persons served, employees or visitors, determined to be a reportable law violation, or (c) a suicide attempt that results in a serious medical emergency/injury to any person in the care of the organization or on the organization’s property.
Every effort will be made to protect the rights of the persons involved in a critical incident, especially their confidentiality. No information will be released without the written consent of the person involved unless it is an incident that requires reporting to local authorities within 15 minutes or emergency medical information that is permissible through prior consent at orientation to services.
In response to a physical injury or medical emergency incident, organizational policy and procedure will be followed. If it appears that medical assistance is needed, the staff member will ask the individual involved for their permission to seek help. If the individual refuses, or otherwise does not consent, but requires medical attention based on the staff member’s observation, the staff member should seek medical personnel to offer assistance.
Once the immediate situation is stabilized, promptly report all incidents that fit the reporting criteria. If you are unsure if an incident fits the reporting criteria, contact your supervisor for guidance. Staff members who witnessed the incident, or to whom an incident was reported, should complete the Critical Incident Form as soon as the situation is within control. Upon completion, the form will be routed to the Critical Incident Officer. The Critical Incident Officer will be responsible for further investigation and completing the investigative response form for the reported incident.
Both the completed critical incident form and the completed response will be printed by the Critical Incident Officer and maintained in a locked file of all critical incident reports and responses. The Governing Body will review all critical incidents and responses on an as-needed basis. The CARF standards state that a facility should perform an analysis of all critical incidents at least annually. The review will assess causes and trends, develop strategies and interventions to prevent a recurrence, develop education and training for personnel to minimize future recurrence, and ensure that internal and external reporting requirements are met. This information will additionally be used to assist in the revision of the organization’s risk management plan, insurance coverage, compliance planning, and code of conduct.
All critical incidents are considered confidential information. All printed Critical Incident Reporting forms and distributed copies are to be maintained in a safe and secure location by the staff member possessing them and are never to be reviewed by unauthorized personnel. This includes the person who actually reported the incident; unless that person is one of the lines of authority for reporting critical incidents. All specific information related to the actual event will be contained within the appropriate forum of discussion and is not to be disclosed outside of formats authorized by organizational policy and procedures. Critical incident reports have serious legal implications. They are not to be circulated beyond the outlined pathways of circulation.
In any situation in which a person refuses medical care for an observable medical condition resulting from a critical incident, it should be clearly documented on the critical incident form that medical care was refused.
Completing the Critical Incident Form
The staff member involved or a staff member witnessing the critical incident should complete the form. The date, time of the event, and location should be explicitly identified. The report should contain information about the patient, staff member, or visitor involved in the incident.
For a patient, the identity and chart number should be completed for each patient involved in the incident. The identity and position of the staff members involved should be noted as well. The identity of any visitors involved in a critical incident should also be noted and the reason they are in the facility or on the property should be noted. The description should be concise and to the point, including facts only, i.e., what, when, who, how and where.
The type of incident should be defined, i.e., accidental injury to a patient, medical emergency, assault, etc. A description of the event, including a specific behavioral description of the event, should be given in addition to listing all witnesses. Identification of any immediate action that was taken to alleviate the situation and the rationale for the actions should also be included and should end with the reporter’s signature, title, and date.
Supporting documentation should be included with the report. Supporting documentation would include any photographs, refusal or medical care forms, progress notes, medication error reports, etc.
All Critical Incident reports are confidential. Any drug, treatment or procedure, equipment, etc. involved in the incident should be listed, and any parts of the body, property, etc., should be detailed.
The incident report should be filed immediately and routed to the appropriate recipients within a 24-hour period. It should be placed in a file reserved for all Incident Reports and should be considered highly confidential. The incident report should not be copied to anyone without the approval of your facility’s Governing Body.
As a reminder, an incident report should be reserved for those issues identified in the “Criteria” section above. The form should never be used for reporting routine issues.
Response to a Critical Incident
An organization should provide prompt and complete responses to persons served, staff members, and visitors needs in situations containing the risk of injury; to call attention to physical situations that need to be investigated or resolved to ensure a safe environment for patients, staff members, and visitors; to determine issues that can be addressed for enhancement or improvement through management and planning, and to manage the risk of situations with potential liability for the organization. Incidents, of a serious nature, that compromise the health and safety of persons served by your facility, its staff members, and visitors, will be documented and reviewed for the purpose of decreasing the likelihood of similar future incidents.
All situations, behaviors, and/or actions meeting the criteria for a reportable incident should be documented and forwarded to the appropriate staff for further investigation and management, as per the procedures contained in the organization’s Critical Incident Reporting policy.
Review and Investigation of the Critical Incident
Reviews of initial critical incident reports may result in further investigation and clarification to assess outcomes and formulate recommendations. This may include, on a voluntary basis, interviews of persons served and visitors, and interviews of staff members.
The management team will summarize past critical incidents, seek to discover any trends that may be occurring, investigate causes related to trends, and make changes in policy, procedures, and/or operational guidelines, if appropriate. This information will additionally be used to assist in the revision of the organization’s risk management planning, insurance coverage, compliance planning, and code of conduct.
Lines of Authority for Reporting
The lines of authority for reporting a critical incident may vary according to the supervisory structure of a facility. In its simplest form, the person who first becomes aware of a potential critical incident should immediately report it to their immediate supervisor who should, in turn, report it to the Critical Incident Officer. (If your facility has a more complex infrastructure, your lines of authority for reporting should be defined in your policy and procedure manual).
The Critical Incident Officer is responsible to ensure that the report is properly written up by the person who discovered the incident, and for following up with any preliminary investigation of the incident after the immediate and necessary response to the incident (calling 9-1-1, rendering initial first aid, etc.).
Once the critical incident has been contained and/or addressed and any urgent notification of local authorities completed, the Critical Incident Officer should immediately contact the Governing Body and/or primary owner/sponsor and advise them of the incident. Any incident should be followed up completely until a reasonable, legal, moral and ethical resolution has been reached and all involved parties are notified appropriately of the conclusion of the incident.
Procedures should be established to safeguard against any future incidents of a similar type, and any identified potential threats should result in the implementation of timely and appropriate corrective action(s). The plan of action should include ongoing monitoring of any corrective actions until their effectiveness is established.
Reporting to the Appropriate Authorities
In regard to reporting critical incidents, there is a protocol for reporting them within the facility (Lines of Authority above), but there is also a process for reporting them outside the facility. Although all critical incidents must be reported internally, not all must be reported externally; for example, a personal injury accident would only be reported internally – to the Governing Body (including the Critical Incident Officer), the facility’s insurance company, and possibly the facility’s legal representative. Because these are vendors for the facility, they are considered internal.
Aggravated assault would have to be reported internally and externally to the local authorities, i.e., police or sheriff’s department, etc. The first step for reporting may be to call the local police or sheriff’s department, depending on the nature of the incident. An example of this would be an assault on a patient, visitor, or staff member, or alleged criminal activity like selling illicit drugs on the premises.
In the event of diversion, the DEA and the State Methadone Authority and, in some cases, the state Pharmacy Board should be notified. In some circumstances, the Federal Bureau of Investigation (FBI) and/or the state bureau of investigation may need to be contacted. It is also possible that the local and/or regional drug task force should be notified.
Other agencies or entities that might require notification would be the state’s equivalent of the Department of Family and Children’s Services (for abuse and/or neglect), attorneys for the organization, insurance companies (personal injury or property damage), or the Food and Drug Administration (FDA) Adverse Event Reporting Program, etc.
Any suicide or other death that occurs on the premises, including a drug-related death of any person served must be reported to various local, state, and federal agencies. This might include the Sheriff’s Department, FBI or state Investigation Bureau, the state’s Office of Regulatory Services or a comparable state agency, i.e., Healthcare Facility Regulatory Division or Department of Community Health, the DEA, the State Methadone Authority, or the state’s Pharmacy Board. SAMHSA may also require notification of any narcotic treatment program-related death. The facility’s accreditation agency (i.e., CARF) should also be notified
Follow-up by an Accreditation or Regulatory Body
If an accreditation organization or other regulatory body determines that an adverse event involves an immediate threat to the care or safety of an individual, if the adverse event is believed to indicate the possibility of serious operational or personnel problems in the treatment program, if there has been more than one serious adverse event within a six-month period, or if the adverse event has the potential to undermine public confidence in the treatment program, the accreditation organization and/or other regulatory body may consider making an unannounced visit to a treatment program or facility to ensure the health and safety of the facility’s patients, visitors and/or staff members.
Establishing a Critical Incident Checklist for Your Facility
After determining the lines of reporting authority, each facility should tailor a Critical Incident Reporting policy to fit its hierarchy. Each facility should develop a checklist for internal and external reporting in order to follow up and bring closure to each incident report. This would involve taking each type of critical incident (See Criteria for Completing a Critical Incident Report above) and charting the agencies that must be contacted. See the chart example below.
Establishing procedures to safeguard against critical incidents is of the utmost importance. In the event incidents do occur, proper reporting, tracking and trending should result in the implementation of timely and appropriate corrective action(s) and the development of proactive measures to prevent such incidents in the future.
Critical Incident Checklist (Example)
| Description of Incident | Report Internal / External | Possible Agencies to Report to: |
| Physical injury to a patient, visitor or staff member on your facility’s property | Internal | Emergency Services if required Immediate Supervisor Critical Incident Officer Insurance Carrier Legal Representative |
| Physical assault on your facility’s property between two persons served | Internal & External | Immediate Supervisor Critical Incident Officer Local Police or Sheriff’s Dept. |
| Alleged neglect or abuse | Internal & External | Immediate Supervisor Critical Incident Officer Dept. Family/Children Services |
| Harm to family members or others from ingesting a patient’s medication | Internal & External | Immediate Supervisor Critical Incident Officer Dept. Family/Children Services State Methadone Authority DEA |
| Medication Diversion | Internal & External | Immediate Supervisor Critical Incident Officer DEA Drug Task Force State Methadone Authority State Pharmacy Board SAMHSA/CSAT CARF |
| Any other death that is drug-related | Internal & External | Immediate Supervisor Critical Incident Officer Local Police or Sheriff’s Dept. FBI DEA State Methadone Authority State Pharmacy Board SAMHSA/CSAT/CARF |