Fla. Admin. Code R. 59A-10.0055 : AGENCY FOR HEALTH CARE ADMINISTRATION — Health Facility and Agency Licensing —10 - INTERNAL RISK MANAGEMENT PROGRAM —10.0055 - Incident Reporting System

(1) INCIDENT REPORTING. An incident reporting system shall be established for each facility. Procedures shall be detailed in writing and disseminated to all employees of the facility. All new employees, within 30 days of employment, shall be instructed about the operation of the system and responsibilities of it. At least annually all nonphysician personnel of the facility working in clinical areas and providing patient care shall receive 1 hour risk management and risk prevention education and training including the importance of accurate and timely incident reporting.
(2) INCIDENT REPORTS. The incident reporting system shall include the prompt, within 3 calendar days, reporting of incidents to the risk manager, or his designee. Reports shall be on a form developed by the facility for the purpose and shall contain at least the following information:
(a) The patient's name, locating information, admission diagnosis, admission date, age and sex;
(b) A clear and concise description of the incident including time, date, exact location; and elements as needed for the annual report based on ICD-9-CM;
(c) Whether or not a physician was called; and if so, a brief statement of said physician's recommendations as to medical treatment, if any;
(d) A listing of all persons then known to be involved directly in the incident, including witnesses, along with locating information for each;
(e) The name, signature and position of the person completing the reports, along with date and time that the report was completed.
(3) INCIDENT REPORT REVIEW AND ANALYSIS. The risk manager shall be responsible for the regular and systematic reviewing of all incident reports including 15-day incident reports for the purpose of identifying trends or patterns as to time, place or persons: and upon emergence of any trend or pattern in incident occurrence shall develop recommendations for corrective actions and risk management prevention education and training. Summary data thus accumulated shall be systematically maintained for 3 years.
(a) At least quarterly or more often as may be required by the governing body, the risk manager shall provide a summary report to the governing body which includes information about activities of risk management as defined herein.
(b) Evidence of the incidents reporting and analysis system and copies of summary reports, incident reports filed within the facility, and evidence of recommended and accomplished corrective actions shall be made available for review to any authorized representative of the Agency upon request during normal working hours.

Fla. Admin. Code Ann. R. 59A-10.0055

Specific Authority 395.0197 FS. Law Implemented 395.0197 FS.
New 1-2-97.