event beyond what is written in the IR. Some institutions have anonymous reporting of IRs, but UCSF does not.
likely it is that you will be a part of the review process and thus hear about the outcomes. If you have filed an IR but haven’t received feedback, it would be appropriate to ask your service chief for follow up.
The most frequent IRs about residents and fellows involve unprofessional behavior, poor communication, slow response time to pages, 10. How can I learn about what comes out of and slow response to requests for orders. If the UCSF Incident Report and Root Cause an IR is filed about you, it will be sent to your Analysis system? program director and/or service chief for review. He or she will contact you to hear The Patient Safety Committee and the Office of about the event from your perspective. GME are partnering to develop Patient Safety Bulletins highlighting key events, what we 7. Is an Incident Report charted in the patient’s have learned about the root causes, and what medical record? Does it go in anyone’s we have done to improve our systems. We personnel file? also conduct a Patient Safety Grand Rounds each year in March. An upcoming GME Grand The incident reporting system is independent Rounds will focus on the IR system and root of the electronic health record. It is always cause analysis. best to consult Risk Management before documenting possible errors in a patient’s record. Incident reports may not be copied and placed in an employee’s personnel file. In fact, they may not be copied for any purpose. An IR is a confidential and privileged communication and must be appropriately handled to protect that privilege. 8. What is a Root Cause Analysis, how is it organized, and who does this? A root cause analysis is a multidisciplinary, structured, retrospective review of an event. At UCSF we perform RCAs on serious, sentinel events as well as near misses. The UCSF Patient Safety Committee has oversight over the RCA itself and is accountable for assuring that improvement actions identified at the RCA are implemented, sustained, and disseminated. Some examples of recent RCAs and the changes that were put in place, have been nicely described in the GME Patient Safety Bulletins that have recently been distributed. 9. Will I hear what happened to the situation about which I submitted an Incident Report? One of the pitfalls of our current system is that we do not do a great job of closing the loop with each person who has filed an IR. In general, the more serious the error, the more 7