12-5 Vt. Code R. 16:3 - Hospital policies, procedures and reporting related to intentional unsafe acts under the Agency of Human Services regulations

“Hospital policies, procedures and reporting related to intentional unsafe acts under the Agency of Human Services regulations”

Each hospital must establish an internal reporting system and develop policies and procedures for ensuring timely identification and reporting of all intentional unsafe acts to the patient safety surveillance and improvement system. The policies and procedures must include:

1. Provisions to ensure that the internal reporting system is easily accessible to all hospital staff;

2. A process for how and when hospital staff submit reports of intentional unsafe acts through the internal reporting system;

3. A designated entity responsible for receiving internal reports;

5. A process for review and ongoing monitoring of all internal reports to ensure timely identification of intentional unsafe acts; and

6. A process for periodic education of hospital staff concerning internal reporting of intentional unsafe acts.