Process incidents

1.    Introduction

1.1.    Target

The Protocol Reporting and Risk Incidents and Calamities (Protocol MRIC) is in line with the policy principles of the Titurel Foundation with regard to quality assurance. The MRIC is one of the quality instruments used: data from the analysis of the reports are used as input in a continuous quality improvement process.

The aim of the MRIC Protocol is to provide a manual for notification, risk assessment and handling, incidents and calamities involving clients and/or employees. It the ultimate goal is prevention of incidents and calamities.

The MRIC Protocol is followed in all cases in which an incident or calamity occurs and risks are reported in which clients and/or employees are involved.

1.2.    Target audience

The MRIC Protocol is intended for all employees of Titurel, including volunteers and interns.

1.3.    related documents

The following protocols have interfaces with the Incidents and Calamities Protocol:

• Complaints procedure
• Code of Conduct

2.       Terms used

2.1.   Incident

An incident in the context of the Protocol MRIC is an unintended event during the care process in which a client suffers material and/or immaterial damage. In some cases also suffers damage to an employee and/or a third party. Any event in which it has not actually caused damage, but damage could have arisen (formerly: near accidents), or when there is a (possible) deviation from care is detected is considered an incident.

Sometimes it is difficult to determine whether a event is serious enough to call it an incident. In that case the possible damage that could have arisen a
determining factor: if it could have ended much less well, there is also talk of an incident and this protocol also enters into force. Also the experience of those involved is decisive: when a client or an employee experiences an event as an incident, then the protocol comes into effect.

• Example 1:
  A client lives accompanied independently and accidentally cuts his finger when peeling potatoes. It bleeds, but it's not serious, a band-Aid paste is enough. See both the client himself and the Titurel employee this event as something that can happen to anyone, without major consequences. This is not seen as an incident.

• Example 2:
  An employee who works with clients with a severe intellectual disability is peeling potatoes and he walks away because the phone rings. One of the clients then takes the knife, without realizing that a knife can be dangerous. He then accidentally cuts himself. although it is not serious and sticking a plaster is enough, does this matter? an incident. It could have ended a lot worse.

• Example 3:
  An employee has a conflict with a client. The client is very angry and scolds the employee. The employee wants an Incident Report Form and fill in calamities, his colleague thinks this is exaggerated. This client yells more often, but he doesn't mean it so bad. The employee felt feel threatened and intimidated by this client and decides to to report. The basic principle is that in case of doubt about the seriousness of a event is always reported under the MRIC Protocol.
  
  

      Also things like theft, unwanted intimacies, (false) fire alarm, violations of the
      code of conduct etc. be classified as incident.

2.2.    calamity

A calamity is an unintended or unexpected event, relating to the quality of care and resulted in death or serious harm to a patient.

Examples are:

• a accident with injury
• a accident with fatal outcome
• brand
• flood with the need for drastic measures such as emergency housing
• aggression.

2.3 Risk

A risk is the probability that a potential hazard will result in an actual incident and the severity of the injury or damage that has as a consequence.

3.    Procedure

3.1.    Why report?

          The MRIC is one of the quality instruments used within the Titurel foundation. The analysis of the various reports of risks, incidents and calamities used to actively look for possible quality improvement. In the analysis unravels what went wrong and when, and it is being investigated whether and how this could have been prevented. Based on this is going to be, when possible, initiated an improvement process or directly measures taken. These measures can be implemented in very different ways lying down, ranging from adjustments in the accommodation, changing of working methods and procedures for deploying a trajectory of professional development.

             The goal is to get as much as possible learning from specific cases, with the aim of improving the quality of concern. We strive for an active reporting culture among our employees.

3.2.    Method

The employee involved reports every incident/calamity as soon as possible as soon as possible but no later than within 2 working days by mail to the mail group MRIC, consisting of the director, teamleider, the Care Coordinators and the secretariat (mail group MRIC notification in address book). When it comes to a MRIC notification about medication, the employee concerned also mails the MRIC to the concerning team. If it concerns an MRIC regarding behavior, the employee the completed MRIC document in Zilliz under the heading “file” of the client concerned(in). In addition, a copy of the notification will also be sent to the personal supervisor of the resident concerned.

             The notification of a incident/calamity is done by means of a report with an established format (see Appendix 3.4 in 3.5). There is a general MRIC format and a specific one for medication. The incident is described in form MRIC, Place, date, involved, cause, how did the employee act, was this possible too been prevented, perceived seriousness of the incident, consequences for individual client, consequences for the group, parent/network contacts. In form MRIC medication is specific discussed what type of error it is and who is there as an employee is responsible.

             The employee concerned is responsible for making the report; the team leader monitors whether actually reported.

          The care coordinator keeps, commissioned from the director, a registration of the notifications made. This one registration is also used to monitor progress, taken measures, etc. and for reports and overviews.

The notification is discussed in the next core team meeting or sooner if there is reason to do so. It core team investigates the cause and determines whether it is possible and necessary to take steps to prevent recurrence. The core team ensures that the measure is taken. The report is then sent by the team leader introduced into the team meeting where it is discussed and, when from application, agreements are made about the measure taken.

If it has been determined that there is a In the event of a calamity, the director reports this to the IGZ within three working days and a basic research analysis carried out in accordance with the requirements of the IGZ. from this consultation becomes, where applicable, immediate follow-up(s) evicted. Also it is assessed whether a measure can be taken to prevent a recurrence of the incident to prevent. If this is the case, the cause of the incident or the calamity is investigated and a measure to prevent recurrence is determined and implemented. The immediate follow-up(s), the conclusion regarding the ability to prevent recurrence (including who will implement this measure and the corresponding deadline) are registered in the improvement matrix.

The incident/calamity and any follow-up of this will be discussed in the next team meeting. The care coordinator makes an analysis of trends and details of the reports every six months. This analysis is discussed in the core team (and during the system assessment) and based on this, the driver takes additional measures if necessary to prevention of repetition of incidents and calamities and ensures these in the quality system. The director supervises the implementation of the measures, reports on this to the Supervisory Board and the Client Council.

3.3 Flow chart

3.4 MRIC Formulieren

Notifications pertains to individual: register it in US

Notification relates to group: register via form,
MRIC General
MRIC Medication