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How report was received:

• Hotline: Enter event report via the institution's event reporting system.
• Online: Review and prioritize events.
• Complaint/Grievance: Gather facts, and refer to patient/guest relations or the appropriate department/individual.

• Ensure the patient is stable, and provide emotional support to the patient/family.
• Assess event for potential harm based on report/cursory electronic medical record review.
• Report any adverse event to the appropriate professional responsible for patient safety events. Activate Care for the Caregiver program and provide emotional support for caregivers and staff.

• Secure the event location (i.e., patient room or procedural area).
• Do not move, turn off, change equipment settings in:
  • Patient room/procedural area – do not allow anyone in the area.
  • All equipment and devices.
  • All disposables (e.g., medication vials, IV bags, catheters.
• Contact clinical or biomedical engineering for assistance.
• Obtain all records: medical record, departmental worksheets, logs (e.g., transports), and schedules (e.g., OR, on-call).
• Identify all individuals involved in the event; determine via medical record review and interviews.
• Note any evidence of additions, corrections, or alterations in the medical record (contact IT to assist with EMR).
• Obtain all monitoring strips/records.
• Secure record of pages via operator or tracking mechanism.
• Secure photos/video recordings (OR/procedural) and/or security monitoring tape.

• Consider additional care provider referrals to Employee Assistance Program (EAP) and/or peer-support program.
• Prepare strategy for ongoing communication with key stakeholders and patient/family.
• Identify a patient/family liaison.
• Advise care providers on appropriate medical record documentation post event.
• Initiate process to hold hospital and professional fee billing.
• Notify appropriate individuals of the event (e.g., claims management, legal counsel, any liability carrier that might be involved).
  • Assist legal counsel in gathering facts/information, as requested.
• Notify residency program directors, as appropriate.
• Contact the unit/program director of each employee to be interviewed.

• Schedule in-person interviews of key staff.
• Determine best physical setting and arrangement for interview.
• Prepare interview strategy, questions, and materials based on document review and event review handbook.
• Outline the subject areas to be addressed in logical sequence.
• Compose questions for each subject area.
• Collect medical records and other documents to establish timeline of events.
• Consider additional care provider referrals to EAP and/or peer-support program.
• Provide interviewees with contact information of interviewer.

EVENT INVESTIGATION AND ANALYSIS

• Identify any potential issues for peer review or other accountability review in accordance with just culture principles.
• Develop investigation strategy.
• Use the following as guidance:  Joint Commission's National Patient Safety Goals; National Quality Forum's Serious Reportable Events; or Centers fpr Medicare & Medicaid Services' "never" events.
• Identify organizational policies and procedures that apply to the event to determine whether they:
  • Were followed, and/or
  • Are in need of revision.
• Flow chart the process, if applicable.
• Conduct a literature review, if applicable.
• Enter all information in the hospital event reporting system.
• Obtain peer review, as appropriate.
• Keep leadership up-to-date on the process.
• Continue to monitor patient/family status and needs.
• Maintain contact with patient advocate/liaison.

• Conduct consensus meeting with leadership and appropriate providers to review findings and determine next steps.
• Meet with malpractice insurer(s) to review findings.
• Implement changes to process, procedures and policies, as appropriate.
• Monitor changes to ensure results.
• In the final step, appropriate personnel will:
  • Meet with patient/family to review findings, present resulting actions to prevent future recurrences of similar events.
  • Determine if it is appropriate to continue to withhold some or all claims to third parties and bills to the patient.
• Offer to discuss financial restitution to the patient / family, if appropriate.