5.3.02 Special incident

Goal and purpose

Notification of the managing director, the members of the board of directors and the clinic directors of special incidents on the premises and in the operation of the hospital. The notification must be made without delay using the reporting channels described so that the management can take appropriate countermeasures and possibly inform the public.

DIN EN ISO 6.1, 10.2.1; JCI QPS.7;

Application

Entire clinic

Description of the process

What events still need to be reported?

Notification and reporting obligations already exist for a number of special incidents due to legal requirements. Reference is made here to the corresponding regulations:

• Reporting of serious adverse events (5.3.01)
• Events during blood transfusions
• Report on radiation protection
• Special incidents according to MPBetreibV (5.3.03)
• Accidents at work
• Accidents involving hazardous biological substances
• Threats to biological safety in connection with genetic engineering work
• Infection Protection Act
• Drug side effects
• Hazardous Substances Ordinance

These events do not usually have to be reported again as a "special incident". In a particularly serious case or if further consequences are feared, further notification may nevertheless be necessary. As a rule, the notification forwarded to the Medical Director should be sufficient.

Reporting channel

• Employee notices a special incident.
• Employee immediately informs superior or representative in the office. If immediate measures are necessary and rule out immediate reporting, the immediate measures take precedence.
• Supervisor or employee takes further measures and informs other persons (e.g. police, fire brigade).
• possibly further notification to the managing director of the clinic, institute or department management.
• The head of the clinic, institute or department shall inform the member of the Executive Board responsible for his area or - if not available - any other member of the Executive Board.
• If the members of the Executive Board cannot be reached (especially outside office hours), the porter can be authorised to contact the members of the Executive Board (telephone numbers are available from the porter).
• Board member informs all other Board members as required and orders necessary measures (informing other bodies such as supervisory authority, health and environment authority, hygiene institute).
• Supervisor and employee subsequently prepare a report.

Responsibility, qualification

Message	By each employee, as far as possible via their own line manager
Receipt of the notification	By the member of the Executive Board responsible for the business area, or another member of the Executive Board if they cannot be reached.

Documentation

The notification should preferably be made in writing. The notification can be sent as a fax message. The form in Appendix 1 can be used for this purpose. In the event of urgency or imminent danger, immediate notification may also be necessary verbally. For your own security, a written report should be submitted later. If appropriate, a note should be made of the course of events and the presumed reasons for the particular incident.

Notes and comments

Incident reports only have to be submitted once, regardless of whether they occurred as a treatment-related event (serious adverse event) or were reported to the authorities under one of the above-mentioned regulations or fall under the term "special incidents".

Applicable documents

MP Safety Plan Ordinance
Infection Protection Act

Terms

Attachment