Hospital legal department

Up  Home

Below is an example of a hospital policy regarding legal activities. The point here is the amount of detail and specification given this policy. Lawsuits regarding malpractice are largely connected to state law, however, hospitals legally oversee activities within their catchments in most cases.

Administrative Policies and Procedures
Last reviewed: 01/22/02
Effective date: 11/01/01

SUBJECT:
Patient Event Management and Reporting, including Sentinel Events

POLICY:

A patient or visitor event is defined as any unusual or unexpected incident which is not consistent with the routine safe delivery of patient care or operations of the hospital. The “Patient/Visitor Event Report Form” should be completed for any events involving: little or no injury (i.e. accidentally being hit by a door) where NO suggestion of litigation is made; or any untoward occurrence including accidents, assaults, and misconduct involving visitors.

If a patient incident occurs at the Xxxxxx Institute, the Incident Report form should be completed and faxed to the Xxxxxx Management Company at xxx-xxx-xxxx.

If a patient falls within the Xxxxxx Institute, the “Adult or Pediatric Fall Data Collection Form” should be completed.

If an equipment failure causes a patient injury, the Xxxxxx Hospital Legal Department should be contacted immediately and the equipment involved should be removed and given to Clinical Engineering for inspection and evaluation. The “Patient/Visitor Event Report Form” should also be completed.

A sentinel event is an event in the hospital that may have caused significant patient injury or death (i.e. wrong surgery, patient suicide, infant abduction, transfusion of the wrong blood, etc.) If you think a sentinel event has occurred, call the Xxxxxx Hospital Legal Department at x-xxxx immediately.

RESPONSIBLE INDIVIDUAL(S) AND PROCEDURE:

Departmental Personnel:

1. Attends to the injured patient and asks another staff member to immediately notify the nearest physician on the floor. Stays with the patient at all times.

Physician Responding to the Call for Help:

1. Determines if immediate medical attention is needed and calls a code if necessary.

2. Asks the Departmental Personnel to escort the injured patient to the Xxxxxx Hospital Emergency Room, if required, and to call the patient’s on-site primary care provider, if applicable.

Clinical Manager (does ONE of the following):

1. Fills out a Xxxxxx Hospital “Report of Patient/Visitor Event Form” for patient events where no suggestions of litigation are made. Keeps a copy of the form, makes copies for the division’s Medical Director and the Assistant Administrator (Operations or Business Development and Network Operations), and forwards the original copy to Performance Improvement Committee Chairman for future reference.

a. For patient events at Xxxxxx, follow the above procedure and forward a copy of the form to the Nursing Administrator at x-xxxx.

b. For patient events at Xxxxxx, complete a Xxxxxx at Xxxxxx Incident Report form and follow the above procedure. In addition, fax the completed Incident Report to Xxxxxx Management Company at xxx-xxx-xxxx and notify the Xxxxxx Management Company at xxx-xxx-xxxx.

2. Fills out an appropriate Xxxxxx Medicine “Fall Data Collection Form” to document a patient fall. Keeps the original copy and forwards copies of the form to Xxxxxx Director of Nursing, the Assistant Administrator (Operations or Business Development and Network Operations) and Xxxxxx Hospital’s Coordinator of Nursing Clinical Quality (Administration 220). This form must be signed and dated by the individual completing the form.

§ Fall Data Collection form for Patient Events at the Xxxxxx Institute at Johns Hopkins Hospital.

§ Fall Data Collection form for Patient Events at the Xxxxxx Institute at Green Spring Station.

3. Calls the Xxxxxx Hospital Legal Department (x-xxxx) if an equipment failure causes a patient injury. Removes the equipment involved and calls Clinical Engineering (x-xxxx) for an inspection and evaluation. Completes a “Patient/Visitor Event Report Form”. Keeps a copy of the form on file, makes copies for the division’s Medical Director and the Assistant Administrator (Operations or Business Development and Network Operations), and forwards the original copy to Performance Improvement Committee Chairman for future reference.

4. Calls the Xxxxxx Hospital Legal Department (x-xxxx) if a sentinel event (an unexpected major patient injury) occurs or if the patient/family expresses dissatisfaction and indicates that they are seeking legal counsel.

Xxxxxx Hospital Legal Department: Offers immediate legal counsel.
Also see Our Accomplishments.