HomeMy WebLinkAboutunusual-occurrence-policy-and-formADMINISTRATION: QUALITY IMPROVEMENT May 31, 2017
UNUSUAL OCCURRENCES
UNUSUAL OCCURRENCES
Approved:
Medical Director EMS Director
I. PURPOSE
A. To establish a peer-to-peer report and response mechanism for resolving issues
and incidents that are reportable but are not a threat to public health and safety
or the integrity of the EMS system.
B. To establish a mechanism for reporting and investigating issues and incidents
which pose a threat to the integrity of the EMS system and/or possibly
constitute a violation of California Health and Safety Code Section 1798.200
et seq.
C. To set standards for regular reporting of incidents to the EMS Agency for the
purpose of monitoring the EMS system and identification of opportunities for
improvement in clinical outcomes and/or system structures and processes.
II. AUTHORITY
A. California Health and Safety Code, Sections 1797.204, 1797.220, and 1798.200
B. California Code of Regulations, Sections 100147 and 100402
III. POLICY
Overview of Incident Reporting
For minor interpersonal
issues, misunderstandings
or operational issues not
involving patient care.
Resolve as soon as
possible after the incident in
person or by telephone with
supervisors or management
representatives.
If unsure whether the issue
is Level I or II or if the issue
cannot be resolved at this
level, an Unusual
Occurrence Form should be
submitted.
For patient care issues,
complete an EMS Unusual
Occurrence Form and email,
fax or mail to provider
management. This includes
commendations.
For system issues involving
patient care, email, fax or
mail report to the EMS
Agency.
Reporting party may also call
provider management or the
EMS Agency to verbally
report an incident which will
be documented on an
Unusual Occurrence Form by
the provider.
Includes, but not limited to
incidents involving:
Clinical acts or omissions
that may be a threat to
public health and safety or
considered negligent or
contributing to poor patient
outcome;
Violations of EMS policies
and treatment protocols
that may result in poor
patient outcome; and
Use of intoxicants or
impaired ability due to
alcohol or drugs while on
duty.
Report to the EMS Agency
within 24 hrs.
ADMINISTRATION: QUALITY IMPROVEMENT May 31, 2017
UNUSUAL OCCURRENCES
UNUSUAL OCCURRENCES
Approved:
Medical Director EMS Director
A. Peer to Peer Reporting:
Any incident or event such as minor interpersonal conflicts, misunderstandings and demeanor
issues that are unrelated to patient care activities or minor operational issues.
B. Unusual Occurrence Reporting
Any incident or event which the reporting party believes warrants reporting to another EMS
system participant shall be documented and forwarded by the reporting party to all other
agencies involved.
Reportable incidents or events include, but are not limited to:
(1) Policy or protocol violations not related to clinical care or patient outcome;
(2) Deviation from authorized use of supplies or equipment;
(3) Documentation error or omission not related to patient care;
(4) Communication errors;
(5) Destination errors with no impact on patient outcome;
(6) Near miss incidents; and
(7) Operational (non-clinical) issues.
(8) Commendations may also be submitted to communicate exceptional care by an
individual or group of providers.
Copies of all supporting documents, such as PCRs, hospital records, dispatch logs, etc. must be
included. The EMS Agency shall log all Unusual Occurrences for the purposes of data collection and
analysis. In the event that a recipient of an Unusual Occurrence fails to respond, or provides an
inadequate response, the reporting party may inform the EMS Agency of the failure and request
follow-up action on closure reporting.
C. Mandatory Reporting
I. Any event that is actionable pursuant to Health & Safety Code Section 1798.200 shall be
reported, within 24 hours, to the EMS Agency using an Unusual Occurrence Form.
II. Reportable events include, but are not limited to:
(1) Use of intoxicants or impaired ability due to alcohol or drugs while on duty as an EMS
provider.
(2) Clinical acts or omissions that may be considered negligent or possibly contributed to
poor patient outcome.
(3) Deviation from EMS policy or protocol that may result in a poor patient outcome.
(4) Any act or omission that constitutes a threat to public health and safety.
(5) Any event where recurrence would have a significant chance of adverse outcome.
III. Any individual with direct knowledge of a Mandatory Reporting incident is required to
complete a written report and submit it directly to the EMS Agency within 24 hours.
Employers may require concurrent reporting internally, but shall not preclude, inhibit, or delay
direct reporting to the EMS Agency.
ADMINISTRATION: QUALITY IMPROVEMENT May 31, 2017
UNUSUAL OCCURRENCES
UNUSUAL OCCURRENCES
Approved:
Medical Director EMS Director
IV. Unusual Occurrence forms must include copies of all pertinent documentation, including but
not limited to:
(1) Patient care records
(2) Dispatch logs
(3) Written statements by involved personnel
(4) Summary of initial investigation and actions taken by agency (when applicable and
available).
V. The EMS Agency shall lead Mandatory Reporting Investigations
A. All providers shall assist the EMS Agency and complete requests in the time frame
determined by the EMS Agency investigator.
B. EMS provider agencies shall make available all personnel involved with or having
knowledge of the incident for interviews by the EMS Agency investigator.
C. Provider agencies shall allow the EMS Agency access to proprietary or confidential
information directly pertinent to the investigation.
D. All Mandatory Reporting investigations shall be completed within 30 days or as
soon as reasonably possible.
E. The EMS Agency shall provide a report of the findings and actions to the reporting
party.
F. Investigative reports will not disclose confidential or proprietary information
collected during the investigation.
G. Final reports may be delayed indefinitely by the EMS Agency if their release will
compromise another investigation of the incident or involved personnel being
performed by another regulatory or investigative authority.
D. Provider Reporting
1. All EMS providers will submit a report, at intervals determined by the EMS Agency, using a
standard format developed by the EMS Agency, which includes the following elements:
a) A summary of all issues received and actions taken related to the delivery of EMS
and/or patient care.
b) A summary of all Exception and Mandatory Reporting incidents received and
actions taken.
c) An analysis of any trends identified in the types of incidents being reported.
d) The status of all open Unusual Occurrences and Mandatory Reporting
investigations, including work and remedial actions in progress.
e) A summary of quality assurance and performance improvement activities to include:
ADMINISTRATION: QUALITY IMPROVEMENT May 31, 2017
UNUSUAL OCCURRENCES
UNUSUAL OCCURRENCES
Approved:
Medical Director EMS Director
(1) Any audits required by the EMS Agency.
(2) Any education pertaining to clinical care or EMS operations.
(3) Any internal projects in progress.
2.A Confidentiality Notice should be placed on all confidential faxes and e-mails.
Faxes/E-mail may contain confidential information. Do not read this e-mail if you are not the intended recipient.
This fax or e-mail transmission, (and any documents, files or previous e-mail messages attached to it) may
contain confidential information that is legally privileged or is made confidential by statute. If you are not the
intended recipient, or a person responsible for delivering it to the intended recipient, you are hereby notified
that any disclosure, copying, distribution or use of any of the information contained in or attached to this
transmission is STRICTLY PROHIBITED. If you have received this transmission in error, please immediately
notify us by phone (insert name and phone #) or e-mail, and destroy the original transmission and its
attachments without reading or saving in any manner.
Alameda County EMS Agency Unusual Occurrence Form
All of the following information must be documented on this form
This form may be completed electronically - ‘tab’ through the fields.
The form can be sent as an e-mail attachment: ‘file’>>’send to’>>’mail recipient as attachment’
Submit this form to: alco.uo@acgov.org PCR attached
Other(s) involved
Witness(es) (persons familiar with incident; include
name, title, department, relationship):
Nature of Occurrence
1. Check all appropriate boxes 2. Attach PCR
If yes, contact the EMS Medical Director at (510) 618-2042
Specific issue _______________________________________________________________________
Details of Occurrence
Immediate efforts to resolve this issue:
TREND REPORT INFORMATION:
Affecting
Not Affecting
Revised 05-31-17 *See reverse
*Threat to Public Safety as defined by Health and Safety Code 1798.200
Any of the following actions shall be considered evidence of a threat to public health and safety and
may result in the denial, suspension or revocation of a certificate or license issued under this division
or in the placement on probation of a certificate or license holder under this division.
1.Fraud in the procurement of any certificate or license under this division
2.Gross negligence
3.Repeated negligent acts
4. Incompetence
5.The commission of any fraudulent, dishonest or corrupt act related to the qualification,
functions and duties of pre hospital personnel
6.Conviction of any crime which is substantially related to qualification, functions and duties of
pre hospital personnel
7.Violating or attempting to violate directly or indirectly any provision of this division
8.Violating or attempting to violate federal or state statute or regulation which regulates
narcotics, dangerous drugs or controlled substances
9.Addiction to the excessive use of or the misuse of alcohol beverages, narcotics, dangerous
drugs or controlled substances
10.Functioning outside the supervision of medical control in the field care system operating at the
local level, except as authorized by any other license or certification
11.Demonstration of irrational behavior or occurrence of a physical disability to the extent that a
reasonable and prudent person would have reasonable cause to believe that the ability to
perform the duties normally expected may be impaired
12.Patient Maltreatment: verbal or physical occurrence identified which harm, insult, neglect or
abuse the patient.
13.Controlled Substance: Loss/ broken narcotic vials / defective /Incorrect counts