[Clinic name]
Controlled document
[Address]
[Registration or licence number]
Incident and calamiteit reporting procedure
1Purpose
- 1.1This procedure sets out how [Clinic name] reports, investigates and learns from incidents and near misses, so that each one leads to a change that sticks.
- 1.2Staff report without fear of blame, and the clinic looks for causes in its systems before it looks at individuals.
2What to report
- 2.1Any event that harmed or could have harmed a patient, a visitor or a member of staff, including near misses.
- 2.2Medication errors, missed or delayed results, records shared in error, and any breach of patient data.
3Reporting
- 3.1A calamiteit reaches the IGJ within 3 working days of being established.
- 3.2The report records what happened, when, where, who was involved, and what was done at once.
- 3.3Where a patient was harmed, the patient is told, given an apology and kept informed of what the clinic finds.
4Investigation
- 4.1[Name, role] grades each incident by severity within [2] working days, and decides the level of review.
- 4.2The review uses the record and the audit trail to establish what happened, in order, with times and names.
- 4.3The review names the causes, the actions, an owner and a date for each action.
5Learning
- 5.1Each incident and its actions are discussed at the next governance meeting, and the discussion is minuted.
- 5.2What changed is shared with every member of staff, and checked [3] months later to confirm it held.
6Review
- 6.1[Name, role] reviews this document every [12] months, and sooner after an incident, a complaint or a change in the regulator's requirements.
- 6.2Each review is recorded with the date, the reviewer and what changed, and the previous version is kept.
- 6.3Staff are told of each change, and their acknowledgement is recorded.
7Where this sits in the IGJ framework
- Goede zorg and the kwaliteitssysteemWkkgz artikel 9, a written internal procedure for incidents
- Meldingen to the IGJWkkgz artikel 11, onverwijld melden bij de inspectie
Calamiteit reported within 3 working days of being established
AAppendix, Calamiteit record
- A.1Date and time of the event ______ Location ______
- A.2Consequence for the patient ______ Unexpected, yes or no ______
- A.3Patient or family informed on ______ By ______ Noted in dossier ______
- A.4Established as a calamiteit on ______ Reported to the IGJ on ______
- A.5Investigation led by ______ Report due ______ Sent on ______
- A.6Measures ______ Owner ______ Date ______
