Module 7: Optimizing Health Systems in LTC
174 7.4 Documentation
Critical Incidents and Mandatory Reporting
Critical incident:
- A safety incident caused by an event/circumstance that could have caused/or did harm a resident, visitor, or staff member
- Each home will have policies and incident reporting system that is focused on quality improvement and is typically not punitive
International Classification for resident safety incidents:
- Near Miss
- No Harm Incident
- Harmful Incident
- Resident Safety Incident
Incident management stages:
- Moments prior to the incident occurring
- Immediate response
- Planning the analysis process
- Analysis and investigation
- Implement and evaluate recommended actions
- Communication and sharing[1][2][3]
Mandatory reporting
- All nurses have a duty to protect patients from harm
- Reporting concerns regarding a fellow health professionals practice may be voluntary or legally mandated and is variable dependent on the nursing regulatory body
- All provinces and territories have mandatory reporting requirements for any criminal offences such as physical abuse and sexual abuse
- In certain jurisdictions, mandatory reporting requirements also includes reporting fellow colleagues for unsafe practice, incapacity, or incompetence
- In certain jurisdictions, the mandatory reporting requirement only include nurses reporting nurses, however, in other jurisdictions nurses are required to report any healthcare provider when a patient is at risk or harmed
- Varying thresholds for what would trigger mandatory reporting exist. In some jurisdictions nurses must report if they have reasonable grounds to suspect misconduct and in others a nurse must have objective evidence of misconduct
- Failure to comply with mandatory reporting requirements may be considered professional misconduct
- There is an opportunity to decrease the variation for mandatory reporting requirements[4][5][6]
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Documentation for critical incidents:Describe the incident
- Describe all persons involved or affected
- Describe actions taken
- Describe the factors that contributed to the incident
- Document in the health record and the incident reporting system
- Some homes will have policies to guide the disclosure process
- Disclosure refers to the process of communicating a resident safety incident to a resident/family/SDM
- Can involve several conversations including, the initial disclosure and the post analysis of the incident when there is more information regarding the cause of the incident
- An opportunity to build trust with residents and family
- Promotes healing for those affected by the incidentThe Canadian Patient Safety Institute, 2012 ↵
- Healthcare Excellence Canada, n.d ↵
- HSO, 2023 ↵
- CSA, 2022 ↵
- HSO, 2023 ↵
- Leslie et al., 2021 ↵