LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 303.05 Reporting Clinical Events Involving Clients
 
  PROCEDURES
  1. Reporting Clinical Events
     
    1. If a clinical event, as defined in this policy, occurs at a program site or during delivery of clinical service at any location, the physical well-being and safety of persons involved shall be the primary consideration. Referrals shall be made immediately to appropriate life-saving and/or safety agencies (e.g., paramedics and/or law enforcement).
       
      1. If an event occurs that is not defined as a clinical event in this policy, do not enter the event into the Safety Intelligence (SI) Reporting System. Clinical Risk Management (CLRM), Intensive Care Division (ICD) if an ICD provider, or Community Reintegration Program (CRP-AB109) may be contacted for consultation at the telephone numbers listed on the first page of the Vizient/UHC Safety Intelligence: Event Report (Frontline Report page).
         
      2. Should there be further questions, contact CLRM via email at DMHSafetyIntelligence@dmh.lacounty.gov.
         
  2. Staff shall immediately report clinical events to their manager or supervisor and enter the event in SI within two (2) business days.
     
    1. A Clinical Event Report (CER) can be entered by staff or managers.
       
    2. A CER may be entered anonymously.
       
  3. Critical clinical events shall be entered immediately into SI once an event has occurred.
     
    1. The Clinical Program Director/Manager or designee shall notify CLRM, ICD, or CRP-AB109 of the critical clinical event and when the event report is entered into SI.
       
    2. CLRM, ICD, or CRP-AB109 staff shall determine appropriate notification to the DMH Director or designee.
       
    3. Upon receiving the notification of a critical event report from CLRM, ICD or CRP-AB109, the DMH Director or designee will determine appropriate notification to the Board of Supervisors.
       
  4. Manager Review of Clinical Events
     
    1. Clinical Program Directors/Managers shall review clinical events reported online within three (3) business days from the report date and take immediate action(s) as indicated. Within 10 business days from the report date, the manager shall enter into SI the results of the managerial review, any corrective actions planned or taken, and recommendations for Department-wide systems revisions or additions that may prevent the reoccurrence of a similar clinical event.
       
      1. Program Directors/Managers shall notify CLRM, ICD, or CRP-AB109 if additional time is needed to complete a CER or managerial review that exceeds the timeframes stated above.
         
  5. Maintaining the Confidentiality of Clinical Event Reporting
     
    1. CERs, or information regarding the existence of a CER, shall not be entered into a client record, printed, copied, distributed, emailed, or faxed to preserve the confidentiality of the report from discovery in the event of a legal matter.
       
    2. The Frontline Reporter page is federally protected and, therefore, shall not be printed.
       
    3. CERs and related correspondence shall be treated as privileged, confidential communication between DMH, Los Angeles County’s third party administrator, County Counsel, and contracted legal counsel in areas of risk management and medical malpractice in preparation for litigation. CERs shall not be made available to anyone other than CLRM, ICD, CRP-AB109 staff, or County agents.
       
    4. CERs entered into SI are a component of the DMH Patient Safety Evaluation System (PSES), a safe space for reporting, deliberation, and analysis of system quality improvements and for reporting into the associated Patient Safety Organization (PSO), as outlined in the Los Angeles County Board of Supervisors Policy 8.040.
       
  6. Clinical event reporting does not preclude reporting required by other bureaus or regulations within DMH, such as to:
     
    1. Health Information Management Director/staff for events related to clinical records (for DMH workforce);
       
    2. Administrative Support Bureau through Accident Investigative Reporting for client/visitor injuries on County property or property damage (for DMH workforce);
       
    3. DMH Human Resources Leave Management staff through Accident Investigative Reporting for work-related employee illnesses or injuries (for DMH workforce);
       
    4. Patients’ Rights Office (PRO) for events involving patients' rights issues;
       
    5. DMH Compliance for potential compliance violations/billing improprieties;
       
    6. DMH Designation Coordinator and PRO for events occurring at Lanterman-Petris-Short (LPS) designated facilities; or
       
    7. Appropriate licensing agency for facilities according to their respective reporting requirements.
       
  7. Quality Improvement
     
    1. CLRM, ICD, CRP-AB109, and designated staff with managerial responsibility for the reporting area shall review CERs for risk mitigation and quality improvement purposes, which includes, but is not limited to, the following processes:
       
      1. CLRM, ICD, and CRP-AB109 staff shall conduct regular reviews of selected clinical events, claims, lawsuits, and trends of reported clinical events with members of DMH Quarterly Clinical Risk Management Committee (QICDC) and selected programs for the purpose of risk mitigation for current or potential claims or lawsuits. They will also seek to improve mental health care by reviewing and recommending necessary system changes.
         
  8. Confidentiality
     
    1. All CERs and related materials submitted to and reviewed by CLRM, ICD, and CRP-AB109 staff, including those presented or discussed at QICDC meetings, are privileged and strictly confidential under state law (WIC 5328(a), EVID 1157(a), and GOV 6254(c)) in preparation for litigation and under federal law if reported in the SI Event Reporting System. (Patient Safety and Quality Improvement Act of 2005)