LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 303.05 Reporting Clinical Events Involving Clients
 
Policy Category:  Clinical
Distribution Level:  Directly Operated and Contractors
Responsible Party:  Clinical Risk Management
 
Approved by Curley L. Bonds, MD, Chief Medical Officer, on April 4, 2022
 
I.  PURPOSE
 
To establish uniform protocols for promptly reporting clinical events involving clients to Los Angeles County Department of Mental Health (DMH/Department) Clinical Risk Management (CLRM) through the online Safety Intelligence (SI) Event Reporting System.

Clinical Event Reports (CERs) shall be used by DMH for evaluating and recommending improvements to the quality of mental health services rendered in DMH directly operated programs and contracted mental health agencies.

Contracted agencies shall develop an internal policy and associated procedures that are consistent with their organizational practices and meet the requirements set forth in this policy.
 
II.  DEFINITIONS
 
Client: An existing client with activity in the past 180 days.

Critical Clinical Event: An event that has generated or may generate governmental and/or immediate community-wide attention and may require a notification by DMH to the Board of Supervisors.

Clinical Event: An event involving a client, whether or not the event occurred while receiving services.
  • Clinical event categories reportable to CLRM include the following:
     
    1. Death – Unknown Cause;
    2. Death – Suspected or Known Cause Other than Suicide;
    3. Death – Suspected or Known Suicide;
    4. Suspected or Known Suicide Attempt Requiring Emergency Medical Treatment (EMT);
    5. Client Self-Injury Requiring EMT (Not Suicide Attempt);
    6. Client Injured Another Person Who Required EMT;
    7. Suspected or Alleged Homicide by Client;
    8. Medication Error/Medication-related Event;
    9. Suspected or Alleged Inappropriate Interpersonal Relationships with Client by Staff;
    10. Threat of Legal Action;
    11. Client Assault by another Client Requiring EMT;
    12. Adverse Drug Reaction Requiring EMT;
    13. Alleged Assault by Staff Member to Client; and
    14. Inaccurate, Absent, or Unchecked Laboratory Data Resulting in a Client Requiring EMT.
       
  • Clinical event categories reportable to Intensive Care Division (ICD) by its providers include all of the 14 event categories reportable to CLRM plus the following additional event categories:
     
    1. Fire-setting;
    2. Absence Without Leave (AWOL) or attempt to AWOL; and
    3. Emergency transfer for medical or psychiatric reasons to an acute care hospital.
       
  • Clinical event categories reportable to the Community Reintegration Program for Assembly Bill 109 clients (CRP-AB109) include all of the 14 categories reportable to CLRM.
 
III.  POLICY
 
All directly operated programs and contracted agencies shall report clinical events identified in the Clinical Event definition through the online SI Event Reporting System.

Clinical Program Managers/Directors shall review clinical event reports for potential improvements following the protocol described in Procedures Section B.
 
IV.  PROCEDURES
 
V.  AUTHORITIES
 
VI.  ATTACHMENT
 
Safety Intelligence Event Report