O-13-101 Clinically Significant Event Follow Up

🎯 Purpose:

Defines the actions to take, communication that should occur, and documentation that should be captured when a clinically significant event occurs.

Definition of “Clinically Significant Event”: Any event that requires an intervention or response immediately, or by the end of the business day to resolve the issue. Any circumstance that does not require this immediate attention is not considered a potential or actual clinically significant event.

Reference policy A-3-186 Client Care: Medication Management for medication events. “It is the responsibility of the clinician, using their professional clinical judgment, to determine if a medication issue meets the definition of “clinically significant.”

Examples:

New or declining wound
Inability to perform/provide ordered treatment

Visit not performed
Client/caregiver refusal of care/treatment affecting their wellbeing
Medication or supplies unavailable

Potential Home Health Acquired Infections
Medication Issue

Adverse reactions to medications (nausea/vomiting/allergic reactions)
Ineffective drug therapy (analgesic that does not reduce pain)
Significant side effects (potential bleeding from an anticoagulant)
Drug interactions (serious drug-drug, drug-food and drug-disease interactions)
Duplicate therapy (generic name and brand name equivalent drugs are both prescribed)
Omissions (missing drugs from an ordered regimen)
Dosage errors (either too high or too low)
Non-adherence (regardless of whether the non-adherence is purposeful or accidental)
Impairment or decline in an individual’s mental or physical condition or functional or psychosocial status.
Discrepancies between the ordered medications and what the client reports they are taking and a response is needed to ensure the client takes the correct dose

Emergent Intervention
Client death or serious injury
Intervention/follow-up required when visiting clinician/case manager is unable to complete to track timely follow-up or implement a resolution
An urgent care need or untimely response from a provider that is significantly impacting patient safety/care.

🔄 Process:

The individual who discovers the significant event will do the following:

Follow applicable process(es)/policy in place
Immediately administer any necessary first aid and/or activate emergency response (911) if indicated
Notify the Provider: Clinically significant events require a phone call and a response to resolve any issues. Any circumstance that does not require immediate attention is not considered clinically significant.
1. If an immediate response is needed to resolve the issue before the clinician leaves the home, they must communicate this urgency to the provider.
2. Refer to O-12-820 Complete CLINICALLY SIGNIFICANT MEDICATION ISSUE Coordination Note to document clinically significant medication issues.
Clinician will notify a Supervisor by phone to report any unresolved clinically significant event and obtain additional guidance. An event is considered unresolved if a resolution from a provider is NOT obtained by the end of the visit (for immediate/urgent care issues) or at the latest by the end of the business day.
1. Responsibilities during call:
  1. Describe the event
  2. State actions taken/planned
  3. Indicate/review any safety concerns and impact to the client/caregiver/employee/care plan
2. Supervisors should refer to O-11-214 Create SUPERVISOR FOLLOW-UP OF CLINICALLY SIGNIFICANT EVENT Note to take appropriate action and document follow-up.
Delegation/Documentation:
1. If the significant event is resolved by the end of the business day, enter the event details into a Narrative Coordination Note.

Refer to the flowchart below for an overview/summary of the action to take in a Clinically Significant Event:

📅 Effective: | 🛠️ Revised: | ✅ Approved: