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Significant Incident Reporting

Significant Incident Reporting. Andrew Berger, PhD Vicki Boyd, PhD Natalie Conner, MS, RN Pacific-Western Region Health Consultants. SIR Statistics. New Online SIR System. Timeline: April-May: altering system based on feedback from beta sites May-June: training for all JCCs

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Significant Incident Reporting

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  1. Significant Incident Reporting Andrew Berger, PhD Vicki Boyd, PhD Natalie Conner, MS, RN Pacific-Western Region Health Consultants

  2. SIR Statistics

  3. New Online SIR System • Timeline: • April-May: altering system based on feedback from beta sites • May-June: training for all JCCs • July 1st: convert to online system • Benefits: • Standardized information will allow reports and analysis of trends • Faster and easier to write the report • Quality improvement!

  4. Electronic Reporting Features • Can be used to help identify problems • Abnormal number of sexual assaults or medical incidents • Track the safety of students • Incidents frequently happening at specific locations or times of day • Find out if certain students more at risk • Younger students? • Students recently enrolled?

  5. New Reports Possible • Compare center incident statistics to Regional and National incidents • Breakdown of region’s medical incidents by type of incident • Average age of student attempting suicide • Average length of enrollment of students attempting suicide in the region • Most common method of suicide attempts

  6. What are the Issues? • Incidents frequently result in inquiries from parents, elected officials, DOL officials, and the media. • Detailed description of the incident, with key details, helps ensure National and Regional Offices have the information they need to respond to inquiries. • Program instructions state “Accurate and full information must be provided”

  7. SIR CategoriesProgram Instruction No. 99-14 • Sexual Assault/Misconduct/Battery • Death • Drug-Related Incident • Attempted Suicide • MEDICAL INCIDENT: Any diagnosis of injury, illness, or disease which is serious or widespread among students and/or staff • Communicable disease outbreak (could be one case if serious disease) • Reaction to medication/immunization • Emergency surgery • Hospitalization • Emergency room treatment

  8. Common Error: OWCP Section Choices • Separation and CA form to OWCP • Injury or occupationally-acquired disease • Medical bills covered and pay continuation benefit • Continuing and CA form in health record • Minor injury or resolved without large expenditure (i.e. insurance coverage used on medical leave, or center provided care) • N/A • Not an injury or occupationally-acquired disease • “Acts of God” (i.e. appendectomy)

  9. Common Error:Resolution and Corrective Action • Resolution means type of separation, continued enrollment, or other (indicate) • Corrective Action refers to actions taken that will reduce the potential for recurrence • Will the actions make a SYSTEM change? • Who will take action? • When? How? • Is there a way to evaluate the system change?

  10. Current RHC Concerns • Increasingly violent nature of incidents on center • Corrective action listed in SIR may not get to root of the problem, so system change may not really occur • Need to be more preventive in nature • What preventive actions could change the outcomes of these incidents?

  11. SIR Case Studies

  12. SIGNIFICANT INCIDENT REPORT #1 CENTER CONTACT PERSON: A. CENTER NAME: B. SIR LOG NUMBER: C. CENTER CODE: D. CENTER OPERATOR CODE: E. INITIAL REPORT _X_ SUPPLEMENTAL REPORT ___ FINAL REPORT ___X__ F. INCIDENT CODE: __10___ ARREST: Yes __ No _X__ If yes: Misdemeanor ____ Felony ____ Was Alcohol Involved: Yes ____ No ____ Unknown _X__ G. DATE OF INCIDENT: 03-13-04 H. NO OF PEOPLE INVOLVED:__2___ PERPETRATORS:__1___ VICTIM:__1__ I. LOCATION OF INCIDENT: ON CENTER __X_ OFF CENTER __UNKNOWN___ J. DESCRIPTION OF INCIDENT: Sexual Assaulted. Jill reports she climbed through the dorm window to have sex with Michael, which is a student. She reports not having sex with the young man she went through the window to have sex with due to him not being able to “get it up.” Another student Bob entered the room, when I was trying to put my pants on, “when Bob jumped on me.” He said “he wanted to be in me for a few minutes” while inside of me then he said, “give me a second cause I didn’t come yet.” He said “I was too tight.” I tried to push him off me, I said “no stop” and he stayed on me. Another student entered the room, named Bill. He tried to pull Bob off me, but he couldn’t. I tried to kick Bob off and then he got up. I put my pants back on and ran out of the room crying.

  13. K. PERPETRATOR INFORMATION: List separately for each individual. Name: SSN: DOB: 10--85 DOE: 01-06-04 Student Status: On Pass __ On Duty _X_ Off Duty/Leave __ Off Duty/AWOL __ Off Duty/AWOL __Off Duty/Other ___ UPDATE 4.23.04: Student was terminated 3/17/04, DID 52-A. STAFF STATUS: N/A MEDICAL TREATMENT STATUS: CENTER RESOLUTION: ZT TERMINATION CODE: L. VICTIM INFORMATION: List separately for each individual. Name: SSN: DOB: 09--84 DOE: 08-19-03 Student Status: On Pass ___On Duty _X__ Off Duty/Leave ___ Off Duty/AWOL _Off Duty/AWOL __Off Duty/Other__ Medical Status: Jill was transported to ER via Residential Staff. She was treated medically and released back to the center. UPDATE 4.23.04: Student was terminated on 3/18/04, DID-51B. STAFF STATUS: OWCP STATUS: _____ Termination and CA form to OWCP __X__ Continuing and CA form in health record _____ N/A CENTER RESOLUTION: N/A ZT TERMINATION CODE, IF APPLICABLE: N/A M. MEDIA COVERAGE: None at this time. N. CORRECTIVE ACTION: We as a center can continue to reinforce our center policy.

  14. Incident #1 • What key information is missing? • Where are the “holes”? • Does the corrective action address the problem?

  15. Example 1: Missing Data • This is the initial and final, but a month between incident and updated information. • Was anyone besides the victim interviewed? • What follow-up occurred? • Why were the students separated? • What is the center’s policy? Resolution meaningless if policy is not clear… • Bed checks? • Climbing through dorm windows? • SART team? • Center education? • Alcohol and/or drug testing? (states unknown…why?)

  16. DATE: April 12, 2004 SUBJ: SIGNIFICANT INCIDENT REPORT#2 CENTER CONTACT PERSON A. CTR NAME: B. SIR LOG NO: C. CENTER CODE D. CTR OPERATOR CODE: E. REPORT: INITIAL SUPPLEMENTAL FINAL X F. INCIDENT CODE:10 - Sexual Assault By Student (s) ARREST: Yes No X If yes: Misdemeanor Felony ____ Was alcohol involved? Yes No X Unknown _____ G. DATE OF INCIDENT: 3-11-04 H. NO. OF PEOPLE INVOLVED: 3 PERPETRATORS: 2 VICTIMS 1 I. LOCATION OF INCIDENT: ON CENTER X OFF CENTER J. DESCRIPTION OF INCIDENT: Initial Report dated: 3-11-04: On 3-7-04 at 11:45p.m., I received a call from the Weekend Acting supervisor who stated that student employee Margaret has accused two male students of sexually assaulting her behind the academic building between 9:00p.m. and 9:25p.m. Student did not want the police involved but, both males were transported home pending investigation by the center’s S.A.R.T team. On 3-10-04 the City Police were called and Officer Roberts arrived on center at 9:30a.m. Student employee Margaret and a witness were transported to Police Headquarters to be interviewed by the Sex Crime Unit. An update will follow.

  17. Updated Report dated: 4-12-04: On 4-2-04, I contacted Det. John of the Sex Crime Unit in reference to complaint no. XX-XXX. He informed me that no charges would be filed against student employees Jim and David for any sexual assault charges. He stated that there were inconsistence in student employee Margaret and the witness story. Student employee Margaret signed a waiver with the City Police stating she will not pursue any charges against the students. Both male students were allowed to return and will be sanctioned according to the center guidelines. K. PERPETRATOR INFORMATION: NAME: Jim SSN: DOB: 3--86 DOE: 7-22-03 STUDENT STATUS: On pass On duty X Off duty/leave Off/duty AWOL Off duty/other _____ STAFF STATUS: On pass On duty Off duty/leave Off/duty AWOL Off duty/other _____ MEDICAL TREATMENT STATUS: OWCP STATUS: Termination and CA form to OWCP Continuing and CA form in health record X N/A CENTER RESOLUTION: Placed on leave pending investigation ZT TERMINATION CODE, IF APPLICABLE: N/A

  18. PERPETRATOR INFORMATION: NAME: David SSN: DOB: 2--87 DOE: 8-12-03 STUD STATUS: On passOn duty X Off duty/leaveOff duty/AWOLoff duty/other STAFF STATUS: On pass On dutyOff duty/leave Off duty/AWOLOff duty/other MEDICAL TREATMENT STATUS: OWCP STATUS: Termination and CA form to OWCP Continuing and CA form in health record X N/A CENTER RESOLUTION: Placed on leave pending investigation ZT TERMINATION CODE, IF APPLICABLE: N/A L. VICTIM INFORMATION: NAME: Margaret SSN: DOB: 11--86 DOE: 01-13-04 STUDENT STATUS: On pass __ On duty X__ Off duty/leave ___ Off duty/AWOL ____Off duty/other______ STAFF STATUS: On pass ___ _On duty ____ Off duty/leave ____ Off duty/AWOL ____ Off duty/other________ MEDICAL TREATMENT STATUS:

  19. OWCP STATUS: Termination and CA form to OWCP Continuing and CA form in health record X N/A CENTER RESOLUTION: Continued enrollment. ZT TERMINATION CODE: N/A M. MEDIA COVERAGE: N/A N. CORRECTIVE ACTION: All student employees are informed on safety measures during their initial enrollment in the program and ongoing throughout their stay in Job Corps. The student employee will be counseled by the CMHC and she will be referred to an off center Sexual Assault Program. She will be monitored by her counselor to ensure she is mentally stable and be supportive of her as she goes through this ordeal.

  20. Incident #2 • What parts are well documented? • What information is missing? • Does the corrective action address the root of the problem?

  21. Example 2: Better…but still has some missing information • Good documentation of: • Dealing with the police • Providing continuous support for the victim • Mentions SART • Missing information/problem areas: • Initial report dated 4 days after incident • Unclear re: timing of police intervention…student a minor; also three days between assault and police notification • Does not mention if SOP and standing orders followed, i.e. who initially was contacted to meet with student at the time of the assault? • Medical treatment status of victim is blank • Part of the corrective action is a further description of medical treatment for victim that occurred (i.e. meeting with CMHC) • CA not completed and placed in health record

  22. SIGNIFICANT INCIDENT #3 A. CENTER NAME: B. SIR LOG: C. CENTER CODE: D. CENTER OPERATOR CODE: E. INITIAL REPORT: __ SUPPLEMENTAL REPORT: __ FINAL: _X_ F. INCIDENT CODE/DESCRIPTION: 63 Suicide Threat If yes: Misdemeanor _____ Felony_______ Was alcohol involved? Yes____ No __X_ Was the student arrested? Yes__ No _X_ G. DATE OF INCIDENT: March 30, 2004 H. NO. OF PEOPLE INVOLVED: _1_ PERPETRATOR:__VICTIM : 1 LOCATION OF INCIDENT: ON CENTER: _X__ OFF CENTER___ DESCRIPTION OF INCIDENT: (INITIAL REPORT 3/31/2004) On 3/30/04, the Center Director (CD) and Center Standards Incentive Officer (CSIO) were notified by several students and Dormitory Staff that Student Maria had climbed out onto a fourth floor roof after telling several students that she was “going up on the roof and jump off”. Staff made an immediate search of all rooftops. They were unable to locate the student.

  23. The search continued to the student’s room, where she was found lying on her bed. The CD and CSIO escorted Student Maria to the Wellness Center where she was evaluated by Nursing Staff. The student denied being on the roof, and/or any thoughts of same. The Wellness Staff member had previously notified the off-duty Wellness Center Manager (WCM) of the incident as it was occurring. The WCM instructed to prepare student for transport to the Hospital Emergency Room for psychological/psychiatric evaluation and follow-up, after the nurse’s evaluation. The student was transported to the ER at approximately 6:45 PM. Student Maria has intermittently been in consult/evaluation with the Center Mental Health Consultant (CMHC) for grief issues of parents’ deaths in 2003. The CMHCs mental health notes state that student does not have a psych history, is free of drugs, denied suicidal thoughts, but is an anxious personality. The WCM has been in contact with members of the ER Staff and psych nurses several times today. The staff have evaluated and re-evaluated Student Maria and recommended the student be seen by an ER Staff Psychiatrist today. The student has been placed on Unpaid Medical Leave pending follow-up, discharge from the hospital and diagnosis.

  24. (Final Report 4/13/04) On 4/01/04, the WCM received phone notification that student Maria had been admitted to Unit 1, the Psychiatric Unit of Hospital. The psych nurse who phoned, reported that the student had been evaluated by a psychiatrist and the decision was made for admission based on the student’s responses and the psychological findings. On 4/02/04, the WCM spoke with student Maria’s primary psych nurse and social worker on the student’s case. Both staff report that Student Maria is being considered for discharge from the hospital on Monday, 4/05/04, pending her response to treatment. The student is responding to therapy and medications are being considered but not yet ordered by the psychiatrist. Provisional Diagnosis is: 309 - Adjustment Disorder with Depressed Mood. On 4/05/04, student Maria was released from the hospital to return back to Center. Student Maria was prescribed Zoloft 50 mg. every day and is scheduled for outpatient counseling at Hospital. Student Maria met with Center Director and Acting WCM upon her return to Center. Student Maria will also be followed on Center by CMHC. Discharge Diagnosis is: 296.90 – Mood Disorder NOS. Student will remain in the program with follow up counseling sessions with the CMHC.

  25. K. PERPETRATOR INFORMATION: NAME: SSN: DOB: DOE: STUDENT STATUS: On pass ____On duty ____Off duty/leave_____ STAFF STATUS: On duty ______Off duty_____ MEDICAL TREATMENT STATUS: OWCP STATUS: ___ Termination and CA form to OWCP ___ Continuing and CA form in Hlth Rec ___ N/A L.VICTIM INFORMATION: NAME:SSN:DOB: 5--1985 DOE: 07/23/2002 STUDENT STATUS: On pass___ On duty __X__ Off duty/leave___ STAFF STATUS: On duty ______ Off duty_____ MEDICAL TREATMENT STATUS: Student Maria was taken to Hospital Emergency Room for psychiatric evaluation and follow-up. The student was evaluated by the ER Staff and psych nurses who recommend a follow-up evaluation by a staff psychiatrist. The student remains in the hospital awaiting follow-up by the psychiatrist.

  26. On 4/05/04, student Maria was released from the hospital to return back to Center. Student Maria was prescribed Zoloft 50 mg. every day and is scheduled for outpatient counseling at Hospital. Student Maria met with Center Director and Acting WCM upon her return to Center. Student Maria will also be followed on Center by CMHC. Discharge Diagnosis is: 296.90 – Mood Disorder NOS. Student will remain in the program with follow up counseling sessions with the CMHC. OWCP STATUS: __Termination and CA form to OWCP __ Continuing and CA form in Hlth Rec X_N/A CENTER RESOLUTION: The Center will provide students with medical care as needed and provide follow-up on-Center with referrals as needed. The Center will monitor student’s condition and ensure any and all prescribed medications are taken. ZT TERMINATION CODE, IF APPLICABLE: M. MEDIA COVERAGE: None N. CORRECTIVE ACTION: Center will continue to provide students with emergency medical care and/or first-aid as needed.

  27. Incident #3 • What parts are well documented? • What information is missing? • Does the corrective action address the root of the problem?

  28. Example 3: Good Documentation… but still room for improvement! • Good documentation of: • Provides relevant background info • Mentions protocol that was followed • Clearly states medical treatment received by student and diagnosis • Includes continuing status in Job Corps • It would be even better if: • Medical treatment status was not simply reiteration of incident description • Not clear why student was not separated, or how it was determined that she is safe to return to center prior to receiving therapy • Corrective action does not address PREVENTION, i.e. are students able to access all roof tops??

  29. Summary: Writing the Narrative • Were standing orders and COPs used? • Was the CMHC consulted? • Was there a history of health problems? • Is an SIR team needed for de-briefing incidents and looking at prevention? • Whose job on center is it to write the SIR? • Information for medical SIR should involve or originate from Health and Wellness Staff • Confidentiality issues

  30. Summary: Taking Corrective Action • What factors led to the incident? • Identifying issues/problems and resolutions • Identifying precursors in the environment • Lighting? • Level of supervision? • Lack of knowledge/need for education? • Teaching in terms students can understand • Role playing/role modeling • Consistent repetitive practice • Lack of policy? • Change in SYSTEM needed? • Involve safety officer • Involve CMHC/other health staff

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