Shared on behalf of Quality and Risk Management
Please be advised, we have revised the Hospital’s policy QM-60 Incident Learning System (ILS) Reporting, Investigation and Trending of Incidents and Near Misses.
Actions Required
Managers – Review this memo and the attached poster with your staff during Safety/Quality Huddles and post in your department. The updated policy will be circulated once approved.
Key Policy Changes
Purpose Change: Detail added to principles of a ‘Just Culture’.
Policy Statement Change: Clarification that incidents involve patients and visitors.
Scope Change: Categories updated.
New Definitions Added:
- After hours: 1600 – 0800 hours Monday to Friday; 24 hours on weekends and recognized holidays.
- Incident Triage Team (ITT): A group of leadership who will meet within 48-72 hours of a critical incident to determine if a Quality of Care (QOC) Review is required, and if so, what type of review.
Procedural Updates:
- Procedure 5.2 updated: To clarify who staff should contact when incident occurs.
- Procedure 5.3 updated: To add references to new appendices and to ILS downtime procedure.
- Procedure 5.6: Explanation of incident classifications.
- Procedure 7: References updated.
Key Process Reminders
Please see the attached poster (below).
To report incidents causing harm to employees, please refer to OHS-os-207 Accident/Incident Reporting and Investigation – Employee.
Please also refer to the Incident Reporting Pathways Flowchart on the iNtranet.
If you have any questions, please email TBRHSC.QualityandRiskManagement@tbh.net.