Incident Reporting

Implementation Date: 12/2021

Date of Last Revision: 1/3/2023

Next Review Due: 1/2/2026

 

Reviewed by VTH Administrative Team: 12/8/2021

Reviewed by VTH Board: 12/9/2021

 

Reviewed by Legal Counsel: N/A

Reviewed by Quality Improvement Committee: 12/10/2021

Subject to modification by the VTH Director without approval.

Policy

Any incident that occurs in the Veterinary Teaching Hospital (VTH), or associated services, that either has, or could have, resulted in a negative consequence for patient care or hospital operation must be reported. Reporting must include submission of a completed Incident Report Form. 

If patient death or euthanasia has occurred as a direct result of the event, a necropsy must be offered at no cost to the client. 

All client communication regarding the event must be documented immediately in the communication log of the patient’s medical record

Guidelines

If charges (other than medications) need to be adjusted from the client’s account because of an incident, a discretionary adjustment form must be completed by the attending clinician or designee (see VTH Policy Bill303: VTH Discretionary Adjustment). If medication charges need removed, communicate this to the VTH Dispensary staff (vthpharmacy@vetmed.illinois.edu)

In the circumstances of an incident resulting in a bite, injury, and/or property damage, additional forms must be completed and submitted within the required time frame. 
If an individual sees or knows something that warrants an adjustment or incident form, an individual may be asked to complete one. 

Events that pose significant liability for the VTH must be reported to the VTH Director’s Office (vthdir@vetmed.illinois.edu) as soon as practical and communications with the client regarding liability or potential restitution will occur through the Director’s office.

Procedure (if applicable)

Follow the steps in the appropriate section below.

Complications not associated with primary condition 

Examples include, but are not limited to, complications associated with venipuncture/catheter site, fever, corneal ulcer, pulmonary disease, GI disease (including colic and diarrhea), infection, lameness, laminitis, mastitis, or temporary airway obstruction developed while hospitalized (unrelated to primary complaint)

1. Notify the faculty overseeing the case.
2. Determine any patient stabilization, additional treatments and monitoring that is indicated to treat the newly developed condition and clearly document in the medical record.
3. Communicate with the client what occurred, the plan for therapy and what is being done. Obtain permission for treatment. Document the conversation in the communication log. 
4. Complete an Incident Report Form.
5. Submit a discretionary adjustment if needed. 

Death, euthanasia, or abortion not expected based on presenting complaint

1. Notify the faculty overseeing the case.
2. Notify VTH administration of the incident by emailing vthdir@vetmed.illinois.edu. 
3. Communicate with the client and offer a necropsy, at no cost to the owner, and document the conversation in the patient’s medical record communication log. 
4. Complete an Incident Report Form. 
5. Submit a discretionary adjustment if needed.

Equipment failure or user error

1. Notify the faculty overseeing the case.
2. Determine if the equipment failure negatively impacted the patient.
3. If the patient was negatively affected, determine any patient stabilization, additional treatments and monitoring that is indicated and clearly document in the medical record.
4. If the patient was negatively affected, communicate with the client what occurred, the plan for therapy and what is being done. Obtain permission for treatment. Document the conversation in the communication log.
5. Complete an Incident Report Form.
6. Submit a discretionary adjustment if needed.
7. Notify the person responsible for oversight of the equipment that failed. 

Husbandry/handling complications

Examples include feeding errors, trauma and complications related to handling or bandaging, and self-inflicted trauma subsequent to E-collar removal in hospital.

1. Notify the faculty overseeing the case.
2. Determine any patient stabilization, additional treatments and monitoring that is indicated to treat and/or minimize the newly developed condition and clearly document in the medical record.
3. Communicate with the client what occurred, the plan for therapy and what is being done. Obtain permission for treatment. Document the conversation in the communication log.
4. Complete an Incident Report Form
5. Submit a discretionary adjustment if needed.

Communication errors

1. Notify the faculty overseeing the case.
2. Identify if the error(s) has led to inappropriate treatment or has negatively impacted the patient. 
3. Determine if any patient stabilization, additional treatments, and monitoring that is indicated to treat the newly developed condition and clearly document in the medical record
4. Regardless of outcome, complete an Incident Report Form. 
5. Submit the applicable adjustment form if needed (i.e. credit adjustment, discretionary adjustment)
6. Notify the person(s) involved in the communication errors.

Damage to property / Public Injury

1. Report any University property damage to the police immediately. Report any public injuries to the police, if necessary. 
2. Notify VTH Administration by emailing vthdir@vetmed.illinois.edu. 
3. Individuals who witness property damage must complete a Public Injury/Property Damage form and complete an Incident Report form. Return forms to VTH Administration as soon as possible. Public Injury/Property Damage Report forms are available on the Intranet or outside the VTH Administration offices. 
4. Complete an Incident Report Form. 

Lab errors

1. Notify the faculty overseeing the case.
2. Identify if the error led to inappropriate treatment.
3. If the patient was negatively affected, communicate with the client what occurred, the plan for therapy and what is being done. Obtain permission for treatment. Document the conversation in the communication log.
4. Regardless of outcome, complete an Incident Report Form. 
5. Submit a discretionary adjustment form if needed.

Medication errors or adverse events related to medication (including anesthesia)

1. Notify the faculty overseeing the case.
2. Determine any patient stabilization, additional treatments and monitoring that is indicated to treat and/or minimize the newly developed condition and clearly document in the medical record.
3. Communicate with the client what occurred, the plan for therapy and what is being done. Obtain permission for treatment. Document the conversation in the communication log.
4. Complete an Incident Report Form. 
5. Submit a discretionary adjustment if needed.

Medication/equipment not sent home

1. Contact the client to determine the best way to get the medication/equipment to them. Document this communication in the communication log.
2. Complete an Incident Report Form.
3. Submit a discretionary adjustment form if needed (e.g., covering the cost of mailing the item).

Definitions (if applicable)

Discretionary Adjustment Form – The form that is submitted to request that non-medication charges be written off. This form can be found at 
https://appserv7.admin.uillinois.edu/FormBuilderSurvey/Survey/UIUCVetMed/admin/adjustment_form/

Incident – An event that occurred which was unexpected and caused difficulties. This includes unexpected complications as well as errors. This includes, but is not limited to, the following:

• Medication/equipment not sent home
• Medication errors and adverse events related to medication (including anesthesia)
• Lab errors
•  Equipment failure
• Death, euthanasia, or abortion which was not expected based on presenting complaint
• Husbandry/handling complications including feeding errors, trauma and complications related to bandaging or E-collar removal
• Complications associated with venipuncture/catheter site, fever, corneal ulcer, pulmonary disease, GI disease (including colic and diarrhea), infection, lameness, laminitis, mastitis, or temporary airway obstruction developed while hospitalized (unrelated to primary complaint)

Incident Report Form – The form that collects data on all incidents. It can be found on each desktop in the VTH with the title ‘Incident Report Form’ and an internet browser icon or by scanning one of the QR codes posted throughout the hospital. 

Significant Liability – Liability that includes the potential for legal action, disruption of operations, or financial restitution equal to or greater than $500.

Veterinary Teaching Hospital (VTH) - The collective clinical services of the Large Animal Clinic, Midwest Equine, the Small Animal Clinic, and the Veterinary Medicine South Clinic.