Incident Investigation Follow-Up Review Form Instructions

Individual Name: Record Individual’s name Incident # Record Incident #DMHDDAS Incident Report and Incident Investigation/Follow-upAudit ToolDate of Incident Date of Review Reviewer Investigator/ Team LeaderRecord the date ofthe incidentRecord the date ofthe ReviewRecord theReviewer’s nameInv: Record theinvestigator’s nameTL: Record the TeamLeader’s nameFacilityRecord the name ofthe facilityInstructions: All information to complete the Incident Report Investigation Review is obtained from the Incident Report andIncident Investigation/Follow-up. For further information related to the Standards, see the DMHDDAS Facility RiskManagement Protocol (FRMP) effective November 1, 2008.Standard for Facility ResponsibilityIncident Report1. All applicable areas on Page 1 of theIncident Report are completedcorrectly.2. All applicable areas on Page 2 of theIncident Report are completedcorrectly.3. All applicable areas on Page 3 of theIncident Report are completedcorrectly.4. All applicable areas on Page 5 of theIncident Report are completedcorrectly.YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. All applicable areas on Page 1 are completed correctly.This standard is NO if:a. Any applicable area on Page 1 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All areas on Page 2 are completed correctly.This standard is NO if:a. Any applicable area on Page 2 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All applicable areas on Page 3 are completed correctly.This standard is NO if:a. Any applicable area on Page 3 that should have beencompleted is blank or completed incorrectly.This standard is YES if:a. All applicable areas on Page 5 are completed correctly.This standard is NO if:a. Any applicable area on Page 5 that should have beencompleted is blank or completed incorrectly.Standard for Supervisor Responsibility:Any “blank” blocks (having zero information or “NA”) in the Investigation should be marked as ”NO,does not meet the standard” in this audit tool.Standard for Supervisor ResponsibilityIncident Investigation/Follow-upYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.1. Immediate steps to SECURE THE This standard is YES if, where applicable, the followingDMHDDAS Incident Report and Incident Investigation/Follow-up Audit Tool Instructions-Effective 11/1/08-Page 1 of 4

Standard for Supervisor ResponsibilityIncident Investigation/Follow-upYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.3. The summary of findings, including areview of the individual’s relevantprogram plan and interventionstrategies (if applicable) incomparison to the activitiesdescribed in #2 are recorded.This standard is NO if, as applicable:a. Elements described in a-g above are not recorded, orb. A clear reason for not recording elements a-g is notdocumented.This standard is YES if:a. Summary findings of the investigation are recorded,including a summary of a review of the individual’srelevant program plan and interventions strategies (ifapplicable) that should have been used compared to theactivities described in #2 above.4. Conclusions from the informationprovided in 1-3 above are recorded.This standard is NO if:a. Summary findings of the investigation are not recorded,orb. Summary findings do not include a review of theindividual’s relevant program plan and interventionstrategies that should have been used compared to theactivities described in #2 above; orc. A clear reason for not recording elements a-b are notdocumented.This standard is YES if:a. The outcome of the incident is recorded.5. Recommendations from theinformation provided in 1-4 above arerecorded.This standard is NO if:a. The outcome of the incident is not recorded, orb. A clear reason for not recording the outcome of theincident is not documented.This standard is YES if:a. Recommendations based on information gathered duringthe investigation to improve the quality of care for theindividual are recorded.This standard is NO if:a. Recommendations based on information gathered duringthe investigation to improve the quality of care for theindividual are not documented, orb. A clear reason for not recording recommendations is notdocumented.Standard for Team Leader ResponsibilityIncident Investigation/Follow-up1. A description of how the incidentaffected the individual is recorded(if applicable).YesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.This standard is YES if:a. The incident’s effect on the Individual s recorded; orb. An explanation is present that the incident did not haveDMHDDAS Incident Report and Incident Investigation/Follow-up Audit Tool Instructions-Effective 11/1/08-Page 3 of 4

Standard for Team Leader ResponsibilityIncident Investigation/Follow-upYesNoCommentsSection may be used to clarify a response given, butmay not be used as a stand-alone response.an effect on an Individual.2. If the YES block is checked,indicating additional follow-up isneeded – additional follow-up isrecorded.This standard is NO if:a. The incident’s effect on the Individual is not recorded,orb. It is not clearly stated the incident did not have aneffect on an Individual.This standard is YES if:a. The YES box is checked on the investigation ANDfollow-up is recorded; orb. The NO box is checked.This standard is NO if:a. The YES box is checked on the investigation ANDfollow-up is not recorded; orb. Neither the YES or No box is checked.DMHDDAS Incident Report and Incident Investigation/Follow-up Audit Tool Instructions-Effective 11/1/08-Page 4 of 4