ROWAN UNIVERSITY POLICY
Title: Clinical Incident Reporting
Subject: Rowan University School of Osteopathic Medicine (RowanSOM)
Policy No: SOM: 2015: 01
Applies: RowanSOM
Issuing Authority: President (signature)
Responsible Officer: Dean of RowanSOM
Adopted: 12/19/14
Amended:
Last Revision: 03/31/15
I. PURPOSE
Incident information will be shared with the Rowan University Quality Committee to assist in the improvement of the quality of patient care and the environment in which the care is given; and with insurance companies as required under the contracts of insurance. Prompt reporting of adverse or unexpected events and events that are not consistent with the routine care of a patient also provides an opportunity for immediate intervention by someone able to assist patients and their families, to capture information while facts are remembered, to conduct an early investigation, to improve documentation of the event, to ensure appropriate communication, and to minimize or prevent litigation.
II. ACCOUNTABILITY
Implementation of this policy is the responsibility the Chairman and Administrator of each clinical department.
III. APPLICABILITY
This policy applies to all RowanSOM healthcare providers.
IV. DEFINITION
Adverse or unexpected events include, but are not limited to unexpected deaths, unanticipated neurological deficits (e.g. nerve injuries, paralysis, sensory deficits, brain damage), substantial disability or disfigurement, medication related issues, medical device problems, misdiagnosis/failure to diagnose/delay in diagnosis, obstetric related incidents, and patient dissatisfaction with treatment outcomes that could result in a claim.
V. POLICY
Rowan University is committed to providing quality health care, and to a timely and appropriate response whenever there is any indication that an adverse health care event may have occurred. This requires an effective Incident Reporting System. It is the policy of Rowan University that the Rowan University Office of Risk Management and Insurance (Rowan Risk Management) must be promptly notified when an adverse or unexpected event occurs during the treatment of a patient in the inpatient or outpatient setting. Risk Management will work closely with the RowanSOM healthcare providers and administrators in reviewing, managing, responding to, and (if necessary) reporting the event. Each event is unique and should be managed on a case-by-case basis, with due regard for the patient's privacy, the need to always be attentive to improving practices, and the potential for adverse claims and litigation.
VI. ATTACHMENTS
A. Attachment 1, Procedure Regarding an Adverse or Unexpected Event
ATTACHMENT 1
PROCEDURE REGARDING AN ADVERSE OR UNEXPECTED EVENT
- When an adverse or unexpected event occurs during the treatment of a patient in the inpatient or outpatient setting, the RowanSOM healthcare provider and/or administrator should promptly notify Rowan Risk Management by telephoning (856) 256-4128 or (856) 256-5742. Such events must be reported as soon as possible, but no later than 24 hours following the occurrence.
Note: If the event occurred in the Emergency Room or inpatient setting, the Hospital incident reporting policies must also be adhered to. - Notification to Rowan Risk Management must be objective and only the facts should be provided. No impressions, opinions, criticisms, or judgments should be made. Be prepared to provide a description of the event, including personnel involved; time, date, and place; immediate actions taken; and current status/outcomes. Personnel should bear in mind that such reports are not necessarily "privileged" or protected from "discovery" in litigation.
- The event should not be discussed with anyone outside Rowan Risk Management except on a need-to-know basis. Decline to discuss the event if any other person should ask you about it.
- Rowan Risk Management and/or the RowanSOM Quality Committee will determine whether an investigation will be conducted (other than within the department or via morbidity and mortality reviews).
- Rowan Risk Management will determine whether an incident could result in a claim, and if so, will put the State of New Jersey Office of the Attorney General on notice to preserve coverage under the RowanSOM Professional Liability Program of Self-Insurance governed by the New Jersey Tort Claims Act (N.J.S.A. 59:1-1 et. seq.).