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Critical Incident Reporting

A Critical Incident is an unexpected and undesirable event that has an adverse impact on the outcome of care that occurs during a Member’s term of care funded through PerformCare.

The submission of Critical Incident Reports (PDF) by Providers is an important ongoing monitoring tool to assess network and case-specific Member safety issues.

PerformCare Policy QI-CIR-001 Critical Incident Reporting (PDF) includes additional information.

Report forms

Critical Incident Report (CIR) categories

Event type

Definition

Death of a Member

All Member deaths regardless of cause that occur during a Member’s term of care funded by PerformCare.

Suicide attempt

The actual occurrence of a potentially lethal suicide attempt that requires medical treatment greater than first aid or the individual suffers or could have suffered significant injury.
All suicide attempts while on provider site or while a provider is present should be reported.

Overdose

Overdose of either prescription, legal, or illegal substances that require treatment greater than first aid or that occur on Provider site or while a Provider is present.

Medication error resulting in the need for urgent or emergent medical intervention

Administration of an incorrect medication, dosage, or a missed medication on a Provider site where a Member suffers a medical consequence that requires urgent or emergent medical treatment to offset the effect of the error.

Fire or law enforcement  

Any event requiring the services of the fire department or law enforcement agency while Member is on Provider site or while a Provider is present.

Serious injury to Member

Injury of a Member while on the Provider site or while a Provider is present that requires medical treatment greater than first aid. 

Life threatening illness of a Member

Any life threatening illness while on the Provider site or while a Provider is present where the Member requires the need for urgent medical treatment.

Elopement

A Member receiving 24-hour care who is out of contact with staff.

Member injury due to restraint or seclusion or improper use of restraint or seclusion

An injury occurs to a Member during a restraint or seclusion that requires medical treatment greater than first aid; or improper use of restraint or seclusion which may include a wrong technique used and use of prone restraint. 

Any conditions that result in a temporary closure of a 24-hour care facility

Flooding, fire, physical damage, etc.  to a 24-hour Level of Care facility that requires the re-location of residents.

Provider Preventable Conditions (PPC)

An umbrella term for hospital and non-hospital acquired conditions and defined as two distinct categories: Health Care-Acquired Conditions (HCAC) and Other Provider-Preventable Conditions (OPPC).

Allegations of abuse by a Provider

Any act of alleged or suspected abuse or neglect of a Member which could include physical, verbal, psychological or sexual abuse, exploitation, neglect or misuse of a Member’s funds.

Allegations of abuse by Peer

Any act of alleged or suspected sexual or physical abuse by a peer while on Provider site or while a Provider is present.

Allegations of abuse by family or adult caregiver

Any act of alleged or suspected sexual or physical abuse, exploitation or neglect by a family member or Adult Caregiver that meet the PA ChildLine Reporting Guidelines.

Consensual sexual contact between peers

Sexual contact between a Member and a peer both under the age of 18 while on Provider site or while a Provider is present that is reported to be consensual by both parties after interviews.

Severe physical aggression

Physical aggression which results in serious damage to property or injury greater than first aid to staff or peers while on Provider site or while a Provider is present.

Other occurrence representing actual or potentially serious harm to a Member

Examples of things that may be reported under this category include:

  • Staff using illegal substances or impaired judgment while supervising Members.
  • Member gaining access to contraband while on the Mental Health Inpatient Unit.

Restraint and seclusion monitoring

Report form: Report of Restraint or Seclusion (PDF).

QI-CIR-003 Restraint and Seclusion Monitoring outlines the process of submitting the Report of Restraint or Seclusion Form.

  • A report of Restraint or Seclusion Form must be completed for all restraints or seclusions that do not result in Member injury requiring treatment greater than first aid for any services that are funded by PerformCare.
    • A Critical Incident Report form must be completed instead of the Report of Restraint and Seclusion Form for the following:
      • If a Prone Restraint occurs.
      • If an injury occurred during a restraint or seclusion.
      • Improper use of restraint or seclusion.
  • Providers must follow all internal policies and procedures, all PerformCare policies, and all applicable regulations related to the use of seclusion and restraint.

2016 CIR and restraint data overview

There were 5664 total CIRs submitted by Providers in 2016 for all contracts.  This is a 27% decrease from 2015, which was the highest reporting year from 2012-2016. The decrease is attributed to continuous education efforts inter-departmentally and to Providers addressing CIR criteria.

Critical Incident Category

Count

Death of a Member

93

Suicide attempt

65

Medication error

7

Any event requiring the services of the fire department, or law enforcement agency

447

Abuse or alleged abuse involving a Member

1168

Any injury or illness (non-psychiatric) of a Member requiring medical treatment more intensive than first aid

267

A Member who is out of contact with staff for more than 24 hours without prior arrangement, or a Member who is in immediate jeopardy because he/she is missing for any period of time

119

Any fire, disaster, flood, earthquake, tornado, explosion, or unusual occurrence that necessitates the temporary shelter in place or relocation of residents

7

Restraint episodes

1844

Seclusion episodes

26

Physical aggression

409

Self-injurious behavior

231

Inpatient hospitalization

213

Other

768

Total

5664

In 2016, there was a decrease in restraint episodes by 509 restraints across all contracts as compared to 2015. Restraints accounted for 33% of CIRs submitted. Of these, 50% were from the RTF level of care which is consistent from the previous reporting year. The second largest level of care reporting restraints is MHIP at 32% which is an increase from 2015. Behavioral Health Rehabilitative Services (BHRS) is third with 16% of restraint CIRs a decrease from 23% in 2015.