{"id":190,"date":"2024-03-06T01:21:29","date_gmt":"2024-03-06T06:21:29","guid":{"rendered":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/?post_type=chapter&#038;p=190"},"modified":"2024-04-08T21:32:24","modified_gmt":"2024-04-09T01:32:24","slug":"7-4","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/chapter\/7-4\/","title":{"raw":"7.4 Documentation","rendered":"7.4 Documentation"},"content":{"raw":"<h2>Critical Incidents and Mandatory Reporting<\/h2>\r\nCritical incident:\r\n<ul>\r\n \t<li>A safety incident caused by an event\/circumstance that could have caused\/or did harm a resident, visitor, or staff member<\/li>\r\n \t<li>Each home will have policies and incident reporting system that is focused on quality improvement and is typically not punitive<\/li>\r\n<\/ul>\r\nInternational Classification for resident safety incidents:\r\n<ul>\r\n \t<li>Near Miss<\/li>\r\n \t<li>No Harm Incident<\/li>\r\n \t<li>Harmful Incident<\/li>\r\n \t<li>Resident Safety Incident<\/li>\r\n<\/ul>\r\nIncident management stages:\r\n<ul>\r\n \t<li>Moments prior to the incident occurring<\/li>\r\n \t<li>Immediate response<\/li>\r\n \t<li>Planning the analysis process<\/li>\r\n \t<li>Analysis and investigation<\/li>\r\n \t<li>Implement and evaluate recommended actions<\/li>\r\n \t<li>Communication and sharing[footnote]<\/li>\r\n<\/ul>\r\nDocumentation for critical incidents:Describe the incident\r\n<ul>\r\n \t<li>Describe all persons involved or affected<\/li>\r\n \t<li>Describe actions taken<\/li>\r\n \t<li>Describe the factors that contributed to the incident<\/li>\r\n \t<li>Document in the health record and the incident reporting system<\/li>\r\n<\/ul>\r\nDisclosure of resident safety incidents in LTC:\r\n<ul>\r\n \t<li>Some homes will have policies to guide the disclosure process<\/li>\r\n \t<li>Disclosure refers to the process of communicating a resident safety incident to a resident\/family\/SDM<\/li>\r\n \t<li>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<\/li>\r\n \t<li>An opportunity to build trust with residents and family<\/li>\r\n \t<li>Promotes healing for those affected by the incidentThe Canadian Patient Safety Institute, 2012[\/footnote][footnote]Healthcare Excellence Canada, n.d[\/footnote][footnote]HSO, 2023[\/footnote]<\/li>\r\n<\/ul>\r\n<h3>Mandatory reporting<\/h3>\r\n<ul>\r\n \t<li>All nurses have a duty to protect patients from harm<\/li>\r\n \t<li>Reporting concerns regarding a fellow health professionals practice may be voluntary or legally mandated and is variable dependent on the nursing regulatory body<\/li>\r\n \t<li>All provinces and territories have mandatory reporting requirements for any criminal offences such as physical abuse and sexual abuse<\/li>\r\n \t<li>In certain jurisdictions, mandatory reporting requirements also includes reporting fellow colleagues for unsafe practice, incapacity, or incompetence<\/li>\r\n \t<li>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<\/li>\r\n \t<li>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<\/li>\r\n \t<li>Failure to comply with mandatory reporting requirements may be considered professional misconduct<\/li>\r\n \t<li>There is an opportunity to decrease the variation for mandatory reporting requirements[footnote]CSA, 2022[\/footnote][footnote]HSO, 2023[\/footnote][footnote]Leslie et al., 2021[\/footnote]<\/li>\r\n<\/ul>","rendered":"<h2>Critical Incidents and Mandatory Reporting<\/h2>\n<p>Critical incident:<\/p>\n<ul>\n<li>A safety incident caused by an event\/circumstance that could have caused\/or did harm a resident, visitor, or staff member<\/li>\n<li>Each home will have policies and incident reporting system that is focused on quality improvement and is typically not punitive<\/li>\n<\/ul>\n<p>International Classification for resident safety incidents:<\/p>\n<ul>\n<li>Near Miss<\/li>\n<li>No Harm Incident<\/li>\n<li>Harmful Incident<\/li>\n<li>Resident Safety Incident<\/li>\n<\/ul>\n<p>Incident management stages:<\/p>\n<ul>\n<li>Moments prior to the incident occurring<\/li>\n<li>Immediate response<\/li>\n<li>Planning the analysis process<\/li>\n<li>Analysis and investigation<\/li>\n<li>Implement and evaluate recommended actions<\/li>\n<li>Communication and sharing<a class=\"footnote\" title=\"Documentation for critical incidents:Describe the incident\n\n \tDescribe all persons involved or affected\n \tDescribe actions taken\n \tDescribe the factors that contributed to the incident\n \tDocument in the health record and the incident reporting system\n\nDisclosure of resident safety incidents in LTC:\n\n \tSome homes will have policies to guide the disclosure process\n \tDisclosure refers to the process of communicating a resident safety incident to a resident\/family\/SDM\n \tCan 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\n \tAn opportunity to build trust with residents and family\n \tPromotes healing for those affected by the incidentThe Canadian Patient Safety Institute, 2012\" id=\"return-footnote-190-1\" href=\"#footnote-190-1\" aria-label=\"Footnote 1\"><sup class=\"footnote\">[1]<\/sup><\/a><a class=\"footnote\" title=\"Healthcare Excellence Canada, n.d\" id=\"return-footnote-190-2\" href=\"#footnote-190-2\" aria-label=\"Footnote 2\"><sup class=\"footnote\">[2]<\/sup><\/a><a class=\"footnote\" title=\"HSO, 2023\" id=\"return-footnote-190-3\" href=\"#footnote-190-3\" aria-label=\"Footnote 3\"><sup class=\"footnote\">[3]<\/sup><\/a><\/li>\n<\/ul>\n<h3>Mandatory reporting<\/h3>\n<ul>\n<li>All nurses have a duty to protect patients from harm<\/li>\n<li>Reporting concerns regarding a fellow health professionals practice may be voluntary or legally mandated and is variable dependent on the nursing regulatory body<\/li>\n<li>All provinces and territories have mandatory reporting requirements for any criminal offences such as physical abuse and sexual abuse<\/li>\n<li>In certain jurisdictions, mandatory reporting requirements also includes reporting fellow colleagues for unsafe practice, incapacity, or incompetence<\/li>\n<li>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<\/li>\n<li>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<\/li>\n<li>Failure to comply with mandatory reporting requirements may be considered professional misconduct<\/li>\n<li>There is an opportunity to decrease the variation for mandatory reporting requirements<a class=\"footnote\" title=\"CSA, 2022\" id=\"return-footnote-190-4\" href=\"#footnote-190-4\" aria-label=\"Footnote 4\"><sup class=\"footnote\">[4]<\/sup><\/a><a class=\"footnote\" title=\"HSO, 2023\" id=\"return-footnote-190-5\" href=\"#footnote-190-5\" aria-label=\"Footnote 5\"><sup class=\"footnote\">[5]<\/sup><\/a><a class=\"footnote\" title=\"Leslie et al., 2021\" id=\"return-footnote-190-6\" href=\"#footnote-190-6\" aria-label=\"Footnote 6\"><sup class=\"footnote\">[6]<\/sup><\/a><\/li>\n<\/ul>\n<hr class=\"before-footnotes clear\" \/><div class=\"footnotes\"><ol><li id=\"footnote-190-1\"><\/li>\r\n<\/ul>\r\nDocumentation for critical incidents:Describe the incident\r\n<ul>\r\n \t<li>Describe all persons involved or affected<\/li>\r\n \t<li>Describe actions taken<\/li>\r\n \t<li>Describe the factors that contributed to the incident<\/li>\r\n \t<li>Document in the health record and the incident reporting system<\/li>\r\n<\/ul>\r\nDisclosure of resident safety incidents in LTC:\r\n<ul>\r\n \t<li>Some homes will have policies to guide the disclosure process<\/li>\r\n \t<li>Disclosure refers to the process of communicating a resident safety incident to a resident\/family\/SDM<\/li>\r\n \t<li>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<\/li>\r\n \t<li>An opportunity to build trust with residents and family<\/li>\r\n \t<li>Promotes healing for those affected by the incidentThe Canadian Patient Safety Institute, 2012 <a href=\"#return-footnote-190-1\" class=\"return-footnote\" aria-label=\"Return to footnote 1\">&crarr;<\/a><\/li><li id=\"footnote-190-2\">Healthcare Excellence Canada, n.d <a href=\"#return-footnote-190-2\" class=\"return-footnote\" aria-label=\"Return to footnote 2\">&crarr;<\/a><\/li><li id=\"footnote-190-3\">HSO, 2023 <a href=\"#return-footnote-190-3\" class=\"return-footnote\" aria-label=\"Return to footnote 3\">&crarr;<\/a><\/li><li id=\"footnote-190-4\">CSA, 2022 <a href=\"#return-footnote-190-4\" class=\"return-footnote\" aria-label=\"Return to footnote 4\">&crarr;<\/a><\/li><li id=\"footnote-190-5\">HSO, 2023 <a href=\"#return-footnote-190-5\" class=\"return-footnote\" aria-label=\"Return to footnote 5\">&crarr;<\/a><\/li><li id=\"footnote-190-6\">Leslie et al., 2021 <a href=\"#return-footnote-190-6\" class=\"return-footnote\" aria-label=\"Return to footnote 6\">&crarr;<\/a><\/li><\/ol><\/div>","protected":false},"author":517,"menu_order":12,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-190","chapter","type-chapter","status-publish","hentry"],"part":63,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/190","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/users\/517"}],"version-history":[{"count":5,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/190\/revisions"}],"predecessor-version":[{"id":669,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/190\/revisions\/669"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/parts\/63"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapters\/190\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/media?parent=190"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/pressbooks\/v2\/chapter-type?post=190"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/contributor?post=190"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/npltc\/wp-json\/wp\/v2\/license?post=190"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}