EXAMPLES FOR CRITICAL INCIDENT ANALYSIS
INCIDENTS REQUIRING CRITICAL INCIDENT ANALYSIS
Death (Note if Suicide suspected)
Emergency Medical Treatment Due To
Injury
Medication Error
Self-Harm
Hospitalization Due To
Injury
Medication Error
Self-Harm
Illness (2 or More Unscheduled Admissions Not Due to Chronic Or Underlying Condition Within 12 months)
A Consumer Harmed Another Person, Who Required
Emergency Medical Treatment
Hospitalization
Apparent or Suspected Abuse or Neglect
Emergency Physical Management
Arrest of Consumer
Staff Called Police in Response to Consumer’s Challenging Behavior
Unauthorized Leave of Absence
CONSIDERATIONS FOR CRITICAL INCIDENT ANALYSIS
Method/Procedure:
Was the recipient’s Person-Centered Plan (PCP) adequate?
Was the recipient’s PCP complete?
Did written policies, protocols, and procedures exist?
Were staff aware of risks and thinking about how to prevent them?
Communication:
How was information provided to staff?
Were there barriers to communication?
Were staff aware of the consumer’s PCP?
Were staff aware of the organization’s procedures, policies and protocols?
Was information/instructions missing?
Was information/instructions confusing or contradictory?
Staff Related:
What were staffing levels at the time of the incident?
What training had staff received?
Did staff have skills required to implement procedures?
Environment:
Was the environment noisy?
How much space was available to consumers and staff?
Was lighting adequate?
Were any physical hazards present?
Had Emergency Response Procedures been developed?
Equipment/Materials:
Was equipment available?
Was equipment used properly?
Was equipment in good condition?
Were surfaces safe?
Death (Note if Suicide suspected)
Emergency Medical Treatment Due To
Injury
Medication Error
Self-Harm
Hospitalization Due To
Injury
Medication Error
Self-Harm
Illness (2 or More Unscheduled Admissions Not Due to Chronic Or Underlying Condition Within 12 months)
A Consumer Harmed Another Person, Who Required
Emergency Medical Treatment
Hospitalization
Apparent or Suspected Abuse or Neglect
Emergency Physical Management
Arrest of Consumer
Staff Called Police in Response to Consumer’s Challenging Behavior
Unauthorized Leave of Absence
CONSIDERATIONS FOR CRITICAL INCIDENT ANALYSIS
Method/Procedure:
Was the recipient’s Person-Centered Plan (PCP) adequate?
Was the recipient’s PCP complete?
Did written policies, protocols, and procedures exist?
Were staff aware of risks and thinking about how to prevent them?
Communication:
How was information provided to staff?
Were there barriers to communication?
Were staff aware of the consumer’s PCP?
Were staff aware of the organization’s procedures, policies and protocols?
Was information/instructions missing?
Was information/instructions confusing or contradictory?
Staff Related:
What were staffing levels at the time of the incident?
What training had staff received?
Did staff have skills required to implement procedures?
Environment:
Was the environment noisy?
How much space was available to consumers and staff?
Was lighting adequate?
Were any physical hazards present?
Had Emergency Response Procedures been developed?
Equipment/Materials:
Was equipment available?
Was equipment used properly?
Was equipment in good condition?
Were surfaces safe?