Incident Reporting System
Document ID: 3PE3E66MX2CW-2-1140
Effective Date: 4/22/2016
Incident Reporting System
1. SCOPE
1.1. System-wide, including Marshfield Clinic Health System, Inc. and its affiliated
organizations who adopt this policy including Marshfield Clinic, Inc., Family Health
Center of Marshfield, Inc., Lakeview Medical Center, Inc. of Rice Lake, MCHS
Hospitals, Inc., and all facilities owned and/or operated by the aforementioned
organizations including all Marshfield Clinic locations, and Marshfield Clinic Regional
Medical Center; however excluding MCIS, Inc., Marshfield Food Safety, LLC, Security
Health Plan of Wisconsin, Inc., and Flambeau Hospital.
1.2. Incidents involving employee health and safety are outside the scope of this policy.
2. DEFINITIONS & EXPLANATIONS OF TERMS
2.1. Reportable Incident: An occurrence or event requiring documentation in the
Incident Reporting System with appropriate follow-up by Marshfield Clinic.
2.2. General Liability Incident: An accident occurring on any Marshfield Clinic premises
involving injury to a patient or any visitor resulting from a slip, trip, or fall or other
event and occurring outside the scope of patient care or related health care
services.
2.3. Adverse Medical Device Incident: An event involving death or serious bodily injury
caused, in whole or in part, by an instrument, apparatus or other article that is used
to prevent, diagnose, mitigate or treat a disease or to affect the structure or
function of the body with the exception of drugs. Incidents involving heparin-
containing flush solutions are considered an adverse medical device incident.
2.4. Product Recall Incidents: Includes a voluntary or mandatory recall; safety alert;
notice of product defect, failure or deficiency; or other similar notices issued by a
manufacturer, vendor, or any federal or state agency and received by Marshfield
Clinic which may impact the health and safety of Marshfield Clinic patients.
2.5. Patient Risk Management Incident: Incident with actual or potential medical
malpractice liability to the Clinic. Risk management incidents include:
Informed consent issues regarding surgical/medical treatment
Unexpected , adverse clinical outcome
Unexpected occurrence during a health care encounter involving patient death
or serious physical or psychological injury or illness, including loss of limb or
function, not related to the natural course of the patient’s illness or underlying
condition
Surgical or procedural complication
Unexpected death, medical or surgical or suicide
Missed/delay in diagnosis
Obstetrical complication/compromised infant
2.6. Patient Experience Incident: Patient and/or family concerns regarding the care
provided to them or their family members at Marshfield Clinic. The care received
When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
version.
Page 1 of 5
Incident Reporting System
Document ID: 3PE3E66MX2CW-2-1140
Effective Date: 4/22/2016
did not meet the expectations set by the patient. These also include the following
types of concerns:
Appointment cancellation or mix-up
Access issues
Delay in receiving results
Excessive waiting time
Requests to change provider
Physicians or staff not returning calls
Duplicate testing
Initial counseling of disruptive, difficult, drug seeking and noncompliant patient
behaviors
Consent issues regarding treatment
Financial concerns, which are unable to be resolved by Patient Financial Services
2.7. Patient Behavior Incident: Those incidents where patients have displayed significant
or recurrent difficult, disruptive, threatening, non-compliant, or drug-seeking
behavior.
2.8. Medication/Chemotherapy Incidents: Incidents related to medication, pharmacy
issues, chemo chemical spills, adverse drug reactions, and chemo medication
issues.
2.9. Patient Privacy Incidents: Incidents related to privacy and/or breach of patient
confidentiality.
2.10. Lab/Specimen Incident: Incidents involving lab testing/reporting, lost specimens,
wrong test(s), transport issues, critical values not called and blood product issues.
2.11. Infection Incidents: Incidents such as airborne isolation breaches, hand hygiene
compliance issues, patient exposure, communicable disease incidents, sterilization
issues, suspected infections, or other infection events.
2.12. Safety/Security/Facility incidents: Incidents related to environment, cleanliness,
safety, auto accidents on premises, parking, abduction, bomb threats, weapons on
premises, theft, and property damage/vandalism
2.13. Unprofessional behavior incidents: Incidents where Marshfield Clinic physicians or
staff exhibit unprofessional behavior including:
Abusive or intimidating behavior towards patients, families, or employees
Defamatory statements
Destruction, theft or inappropriate removal of clinic property
Failure to respond
Intended self-harm or suicide
Procession of dangerous unauthorized materials (firearms, explosives)
Practice issues
Prescribing issues
Sexual misconduct
Suspected alcohol or substance abuse
3. POLICY BODY
The purpose of this document is to provide expectations for reporting incidents
occurring at Marshfield Clinic.
3.1. All Marshfield Clinic physicians, providers, residents, and employees involved or who
witnessed the incident are obligated to report using the Incident Reporting System.
When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
version.
Page 2 of 5
Incident Reporting System
Document ID: 3PE3E66MX2CW-2-1140
Effective Date: 4/22/2016
a. If an individual is unsure whether an event requires reporting, they can seek
guidance from their manager or either the Risk Management or Patient
Experience Departments.
3.2. An incident requires reporting through prompt, accurate and complete submission
of an incident report and requires appropriate follow up with patients and involved
parties.
3.3. The incident report will be complete, accurate and timely by the reporting
employee, physician, provider, or department manager (or his/her delegated
representative) in the area in which the incident occurred. The benefits of prompt
reporting include:
a. Assisting patients and families in real time
b. Protecting Marshfield Clinic, providers and employees from litigation
c. Providing the involved professionals with feedback as appropriate.
3.4. Marshfield Clinic physicians and providers will report hospital-based events, where a
Marshfield Clinic physician, provider, or staff provided or assisted with the care, to
the Risk Management team via the Incident Reporting System, as well as to the
hospital in which the event occurred.
3.5. Factual information about the event should be documented in the patient’s
medical record. Documentation in the patient’s medical record will not reference
incident reporting, legal services, or risk management.
3.6. Special Condition Alerts in the patient’s medical record will not be mentioned to
patients or family members.
3.7. Physicians, providers, and staff will cooperate fully in inquiries and investigations
concerning incidents.
3.8. All reported incidents are investigated and resolved.
3.9. Confidentiality of individuals who are involved and individuals who are reporting is a
high priority. Information is shared on a need-to-know basis only. The resolution of
an incident will not be communicated to reporters, in an effort to protect the
confidentiality of those involved.
3.10. It is the policy of Marshfield Clinic that no one will be retaliated against for
submitting an incident report based upon an honest perception of the events or for
cooperating in good faith in the investigation of an incident. If an employee
believes he or she is being retaliated against for reporting a concern or
participating in a related investigation, he or she may report it to their manager or
the Human Resources department immediately.
3.11. An investigation of incident does not imply wrong-doing.
4. ADDITIONAL RESOURCES
4.1. References:
Intranet site: [Link]
4.2. Supporting documents available:
Incident Reporting System—Risk Management Incident:
[Link]
nt%20Reporting%20System%20–%20Risk%20Management%[Link]
5. DOCUMENT HISTORY
When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
version.
Page 3 of 5
Incident Reporting System
Document ID: 3PE3E66MX2CW-2-1140
Effective Date: 4/22/2016
Version No. Revision Description
1.0 Previously was in Policy Library (policy 4849.0) and was effective on 5/1/12
Updated to include information on confidentiality and no tolerance for
2.0
retaliation. Also to move into Document Control System.
When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
version.
Page 4 of 5
Incident Reporting System
Document ID: 3PE3E66MX2CW-2-1140
Effective Date: 4/22/2016
6. DOCUMENT PROPERTIES
Primary Author: Stueland-Adamski, Nancy
Co-Author(s):
Approver(s): This document has been electronically signed and approved by: Parkhurst,
Brandon L MD on: 4/22/2016 10:53:34 AM
When document is printed it becomes an uncontrolled copy. Please refer to DCS system for most current
version.
Page 5 of 5