Healthcare Incident Response Plan

HEALTHCARE INCIDENT RESPONSE PLAN

Facility Name:    Effective Date:

1. PURPOSE AND SCOPE

This Incident Response Plan establishes the institutional policy, roles, responsibilities, and procedures to detect, respond to, investigate, mitigate and report adverse events, safety incidents, patient safety events, security incidents, and breaches of protected health information (PHI). The plan applies to all employees, contractors, volunteers, and affiliated providers.

2. PLAN OWNER AND CONTACTS

3. INCIDENT CLASSIFICATION

Identify the type of incident (select all that apply):

Adverse clinical event    Sentinel event    Medication error

Patient fall    Equipment failure    Security incident / Workplace violence

PHI / privacy breach    Environmental / building event    Other:

4. SEVERITY AND PRIORITIZATION

Severity Level (select one):   Level I — Immediate threat to life/safety    Level II — Significant harm or major service disruption    Level III — Minor harm or administrative issue

5. IMMEDIATE RESPONSE (FIRST 60 MINUTES)

Initial actions to protect patients, staff, and evidence must be taken immediately. Check actions completed:

Stabilize patient(s)    Secure scene / preserve physical evidence    Isolate affected systems (for IT/security incidents)

6. REPORTING AND NOTIFICATION

Reporting timeline: Initial internal report submitted within of recognition.

Notify the following internal roles (check all that were notified):   Chief Medical Officer    Risk Manager    Compliance Officer

External reporting required (check if applicable):   State regulatory authority    Accrediting body    Licensing board

7. INVESTIGATION AND FACT-FINDING

Date:    Time:    Location:

8. PATIENT / FAMILY NOTIFICATION

Was a patient affected?   Yes    No

9. PHI / HIPAA BREACH RESPONSE

Does the incident involve PHI?   Yes    No

10. CORRECTIVE ACTIONS AND REMEDIATION

11. TRAINING, COMMUNICATION, AND DISCIPLINE

Required staff actions:   Training required    Discipline considered per policy    System/process change required

12. DOCUMENTATION, RETENTION, AND CONFIDENTIALITY

All incident documentation shall be maintained in accordance with institutional record retention schedules and applicable legal and regulatory requirements. Documentation of investigations, corrective actions, and communications shall be considered confidential and access restricted to those with a legitimate need to know.

13. REGULATORY AND EXTERNAL REPORTING REQUIREMENTS

14. REVIEW, TESTING, AND CONTINUOUS IMPROVEMENT

15. LEGAL AND ADMINISTRATIVE CERTIFICATIONS

By signing below, the authorized representative certifies that the facts set forth in incident documentation are accurate to the best of their knowledge, that required notifications and reports will be made in accordance with applicable law, and that the facility will preserve documents and cooperate with internal and external reviews. This certification does not waive any legal privileges or defences available to the facility.

Non-retaliation statement: The facility prohibits retaliation against any individual who reports an incident in good faith or cooperates in an investigation. Violations of this policy may result in disciplinary action.

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