Risk Management & Incident Policies

Risk Management & Incident Management Policy

Sri Lakshmi Multi Speciality Hospital is committed to providing safe, ethical and high-quality healthcare by establishing an effective Risk Management & Incident Management System. The Hospital recognises that proactive identification of risks, timely reporting of incidents and systematic investigation of adverse events are essential to protecting patients, visitors, employees and the organisation.

This policy has been developed with reference to the National Medical Commission (Registered Medical Practitioner – Professional Conduct) Regulations, 2023, the Consumer Protection Act, 2019, the Clinical Establishments (Registration and Regulation) Act, 2010 (where applicable), the Tamil Nadu Clinical Establishments (Regulation) Act, 1997 (where applicable), the Digital Personal Data Protection Act, 2023, applicable Central and State Government healthcare regulations, and the quality and patient safety principles promoted by the National Accreditation Board for Hospitals & Healthcare Providers (NABH).

The Hospital promotes a culture of safety, transparency, learning and continuous improvement by encouraging the reporting of incidents, near misses and patient safety concerns without fear of unfair blame, while ensuring appropriate accountability where required.

Purpose of this Policy

The purpose of this policy is to establish a structured framework for identifying, reporting, investigating, managing and reducing clinical and operational risks. The policy aims to minimise preventable harm, improve patient safety, strengthen organisational learning and ensure compliance with recognised healthcare standards.

This policy supports timely reporting of incidents, objective investigation, implementation of corrective and preventive actions (CAPA), and continuous monitoring to reduce the likelihood of recurrence.

Scope of this Policy

This policy applies to all departments, healthcare professionals, administrative staff, contract personnel and support services at Sri Lakshmi Multi Speciality Hospital. It covers all clinical and non-clinical incidents that may affect patient safety, employee safety, visitors, Hospital property or organisational operations.

The policy applies to clinical incidents, medication errors, patient falls, equipment failures, healthcare- associated infections, documentation errors, security incidents, fire and safety events, biomedical waste incidents, near misses and other events requiring investigation or corrective action.

"Every incident provides an opportunity to learn, improve systems and strengthen patient safety."

Our Commitment to Risk Management

Sri Lakshmi Multi Speciality Hospital is committed to promoting a culture where risks are proactively identified, incidents are reported promptly and investigations are conducted fairly, objectively and confidentially. The Hospital encourages learning from incidents to improve patient safety and healthcare quality.

Risk Identification & Assessment

Sri Lakshmi Multi Speciality Hospital shall proactively identify, assess and manage clinical, operational, environmental and organisational risks that may affect patient safety, employee wellbeing, healthcare quality or Hospital operations. Risk assessments may be conducted periodically or whenever significant changes occur in clinical practice, infrastructure or regulatory requirements.

Identified risks shall be evaluated based on their likelihood, potential impact and the effectiveness of existing control measures. Appropriate mitigation strategies shall be implemented to reduce preventable harm and improve patient safety.

Incident Reporting Policy

All employees are encouraged to report actual incidents, adverse events, near misses and unsafe conditions promptly after they are identified. Reporting enables the Hospital to investigate events, improve systems and reduce the risk of recurrence.

Incident reports shall be submitted to the appropriate supervisor, department head or designated Hospital authority as soon as reasonably practicable. Reporting is intended to support patient safety, quality improvement and organisational learning.

"Timely reporting allows risks to be identified early and corrective actions to be implemented before similar events recur."

Types of Reportable Incidents

The Hospital encourages reporting of all incidents, regardless of whether patient harm occurred. Near misses provide valuable opportunities for learning and improving clinical systems before harm occurs.

Initial Incident Review & Immediate Response

Upon receiving an incident report, the Hospital shall undertake an initial review to assess the severity of the event, ensure patient safety, preserve relevant information and determine whether immediate corrective action is required.

Serious incidents shall be escalated promptly to the appropriate clinical and administrative authorities for further investigation. Immediate actions may include patient assessment, equipment isolation, securing relevant records and notifying Hospital Management where necessary.

Sentinel Event Management Policy

A sentinel event is a serious, unexpected incident that results in death, permanent harm, severe temporary harm or presents a significant risk to patient safety. Such events require immediate attention, comprehensive investigation and timely corrective action.

Sri Lakshmi Multi Speciality Hospital shall ensure that all suspected sentinel events are reported immediately to the appropriate Hospital authorities for urgent clinical review, patient safety assessment and formal investigation.

Root Cause Analysis (RCA)

Significant incidents and sentinel events shall undergo a structured Root Cause Analysis (RCA) to identify the underlying system, process or organisational factors that contributed to the event. The objective of RCA is to learn from incidents and strengthen patient safety rather than to assign blame.

Depending on the nature of the incident, the review may be conducted by an appropriate multidisciplinary team, designated Hospital committee or authorised management representatives.

Corrective & Preventive Action (CAPA)

Following completion of an incident investigation or Root Cause Analysis, Sri Lakshmi Multi Speciality Hospital shall implement appropriate Corrective and Preventive Actions (CAPA) to address identified deficiencies and reduce the likelihood of similar incidents occurring in the future.

CAPA activities shall be proportionate to the level of identified risk and may include process improvements, policy revisions, additional staff training, equipment maintenance or replacement, enhanced monitoring and other quality improvement measures.

Learning from Incidents & Continuous Improvement

Information obtained from incident reports, Root Cause Analyses and CAPA activities shall be used to improve Hospital systems, strengthen patient safety initiatives and support evidence-based organisational learning.

Trends may be analysed through quality meetings, patient safety committees, clinical audits and performance reviews to identify recurring issues and monitor the effectiveness of implemented improvements.

"Every reported incident is an opportunity to improve healthcare systems, strengthen patient safety and prevent future harm."

Roles & Responsibilities of Hospital Staff

Every employee, healthcare professional, consultant, administrative staff member and support service provider shares responsibility for identifying potential risks, reporting incidents promptly and contributing to a safe healthcare environment. Staff members are expected to act responsibly, cooperate during investigations and support continuous quality improvement initiatives.

Hospital Responsibilities

Sri Lakshmi Multi Speciality Hospital is committed to maintaining an effective Risk Management & Incident Management System that promotes patient safety, regulatory compliance and continuous organisational learning. The Hospital shall provide appropriate leadership, resources, training and governance to support effective incident management.

Continuous Quality Improvement (CQI)

Sri Lakshmi Multi Speciality Hospital regularly reviews incident trends, patient safety indicators, audit findings, Root Cause Analysis reports and CAPA outcomes to identify opportunities for system improvement. Lessons learned are incorporated into policies, procedures, training programmes and clinical practices to strengthen patient safety.

Policy Review

This Risk Management & Incident Management Policy shall be reviewed periodically by Hospital Management to ensure continued alignment with applicable Indian healthcare laws, recognised patient safety principles, professional standards and evolving best practices in risk management.

"Effective risk management protects patients, supports healthcare professionals and strengthens organisational excellence."

Contact Information

Questions regarding this Risk Management & Incident Management Policy, patient safety concerns or incident reporting procedures may be directed to the Hospital Administration or Quality Department.

Regulatory & Standards Reference

This Risk Management & Incident Management Policy has been developed with reference to applicable Indian healthcare laws, recognised patient safety principles, professional regulations and healthcare quality standards. These frameworks guide the Hospital's approach to risk identification, incident reporting, investigation, organisational learning and continuous quality improvement.

"Sri Lakshmi Multi Speciality Hospital is committed to fostering a culture of safety, transparency, accountability and continuous learning through effective risk management, timely incident reporting, systematic investigation and continuous quality improvement, in alignment with recognised Indian healthcare laws and our ongoing journey towards future NABH accreditation."