Florida Administrative Code, Chapter 59A‑10 specifies the requirements of the internal risk management program required of all hospitals and ambulatory surgery centers. If the surgery center does not have a licensed risk management working at the surgery center, and contracts with a consultant to provide risk management services, the surgery center must have a risk manager designee who is an employee at the surgery center and available to receive reports of incidents from other employees and medical staff of the surgery center. The risk manager designee appointment must be in writing and approved by the governing body.
In addition to formulating policies and procedures for the risk management program and developing an incident reporting system, risk management must be part of the initial employee orientation program. All new employees must have risk management education within 30 days of hire. And, all employees must have one hour of risk management education annually.
The risk management program, at a minimum, must include:
a. The investigation and analysis of the frequency and causes of general categories and specific types of adverse incidents causing injury to patients;
b. The development of appropriate measures to minimize the risk of injuries and adverse incidents to patients, including education and training;
c. The analysis of patient grievances which relate to patient care and the quality of medical services; and
d. The development and implementation of an incident reporting system.
Certain incidents require reporting to the state with little time for investigation by the risk manager or risk manager designee. It is important that the risk manager designee and risk manager have a method to communicate quickly when an incident occurs. Those incidents that require reporting to the state within 24 hours of the time the risk manager designee or risk manager is aware of the incident include:
· The death of a patient;
· Brain or spinal damage to a patient;
· The performance of a surgical procedure on the wrong patient;
· The performance of a wrong-site surgical procedure; or
· The performance of a wrong surgical procedure.
The 24 hour report must be followed up with a written review of the occurrence submitted to the state within 15 days of the initial date of the incident.
An annual report, completed on a state form, also must be filed by January 31 (or another date specified in notices from the state) to provide a summary of reportable incidents.
At initial and annual inspections, the surveyors will review the risk management program, the incident reports and related action plans, reports to the governing body and required reporting to the state. AHCA may inspect the risk management program at any time.
