Module guide · Clinical

Incident Reporting

The hospital-wide patient-safety incident system, aligned to TJC, AHRQ, NQF, and OSHA reporting frameworks: file an incident, work it through investigation and root cause, escalate to regulators, disclose to the patient, and track corrective actions to completion.

Overview Dashboard Incident list Reporting an incident Incident detail Regulatory queues Good practices

What this module is for

One broad role group can view and file; a narrower subset can close, escalate, and record disclosures.

Who uses it

Physicians, nurses, nurse managers, charge nurses, safety officers, quality, compliance, directors, and admins can view every screen and file an incident. Closing an incident, escalating to TJC or state, marking a legal case, and recording a patient disclosure are limited to admins, directors, quality, compliance, safety officers, nurse managers, and charge nurses.

Where to find it

Open Incident Reporting from the sidebar. A dashboard, plus the incident list, a New Incident form, and six regulatory work-queue screens.

1
File the incident
Classify it, describe what happened, and flag anything you already know applies (sentinel, TJC, state, legal, disclosure).
2
Investigate
Acknowledge, assign an investigator, start the investigation, and run a root cause analysis if warranted.
3
Escalate and disclose
Flag TJC or state reportability, mark a legal case, and record patient/family disclosure where required.
4
Close it out
Every CAPA item must be completed before an incident can close.

A separate module tracks equipment- and quality-specific incidents

This module is the hospital-wide regulatory system. Equipment malfunctions have their own incident log inside the Equipment module, and Quality Management keeps its own internal incident register feeding its own root-cause-analysis workflow, they're not the same records as here.

Dashboard

A hospital-wide overview with drill-down links into whatever needs attention.

Stat tiles

Field	What it means
Open Incidents, Under Investigation, In RCA, Corrective Action
Open Sentinel Events, Overdue CAPA Items, Pending Disclosures, Overdue TJC/State Reports	Highlighted red when nonzero.
Resolved, Closed, Total Reported (Period)

A Monthly Incident Trend chart, plus Open Sentinel Events and Incidents With Overdue CAPA shortlists. Banners flag overdue TJC submissions (past 45 days), overdue state submissions (past 7 days), and pending high-severity disclosures.

Incident list

Search, filter, and export every filed incident report.

Filters

Field	What it means
Keyword, Type, Status, Severity, Date range

Each row shows a SENTINEL or LEGAL badge where flagged, a severity badge, status, reporter, open CAPA count, and a TJC Reportable tag. Export to CSV or Excel.

Low — near miss / no harm

Moderate — monitoring or temporary harm with intervention

High — prolonged harm or permanent harm

Critical — life-threatening or death

Reporting an incident

Anyone with module access can file a new incident.

"Report Incident" form

Field	What it means
Incident Type, Severity*	Type is one of ~55 options grouped by category, e.g. Medication Error, Patient Fall, Wrong Site Surgery. Severity is the 9-point A–I scale.
Incident Date/Time, Reporter, Description*	Description needs at least 20 characters.
Discovery Date/Time, Department, Location, Immediate Action Taken
Physician/Supervisor Notified (name + time)
Affected Patient, Involved Staff, Witness Staff, Assign To
Contributing Factors	Multi-select toggles, e.g. Communication Failure, Staffing Issue, Human Error.
Regulatory Flags	Checkboxes: TJC Sentinel Event, TJC Reportable, State Reportable, NQF SRE, OSHA Recordable, Potential Legal Case. Can be updated later.
Patient/Family Disclosure Status	Defaults to Not Required.
ICD-10-CM Injury Code, LOINC Code
Reporter wishes to remain anonymous	Checkbox.

Incident detail

Status workflow, root cause analysis, CAPA tracking, comments, and attachments, all on one record.

Workflow buttons (status-gated)

Field	What it means
Acknowledge, Assign Investigator, Start Investigation
Start RCA, Complete RCA	Complete requires Root Cause Findings text.
Resolve, Close Incident	Closing is blocked while any CAPA item remains incomplete.
Reopen	Requires a typed reason.
Escalate to TJC, Escalate to State, Mark as Legal Case, Record Disclosure	Gated roles only.

A CAPA panel lets anyone add items and mark them complete; only gated roles can Verify & Close one. Comments can be marked internal-only or attorney-client privileged; attachments carry the same privilege flag. Export as PDF, FHIR, or plain text.

Regulatory queues

Six filtered worklists drawing from the same incident records, so each compliance obligation has its own view.

Queues

Field	What it means
TJC Sentinel Events	Overdue past 45 days from occurrence without TJC submission.
TJC-Reportable Incidents	The broader TJC reporting-obligation flag, distinct from Sentinel Events.
State-Reportable Incidents	Overdue past 7 days without state health-department submission.
Legal Cases	Incidents marked as potential legal liability.
Pending Patient Disclosures	High-severity incidents awaiting patient/family disclosure, per CMS §482.13 and HIPAA.
Overdue CAPA Items	Corrective/preventive action items past their due date, across every incident.

Good practices

Flag regulatory status early, refine it later

The checkboxes on the report form can all be updated on the detail page, don't hold up filing an incident to be certain about TJC/state/NQF classification.

State reportability has a much tighter clock than TJC

7 days vs. 45 days, check the State-Reportable queue daily if your role touches regulatory submissions.

Closing is blocked while any CAPA item is open

Every corrective/preventive action tied to the incident must be completed and verified first, plan investigations with that in mind.

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