§ 2.25.050. Investigation.

Upon notification of an adverse event, the Director of the Health System, or his/her designee, shall promptly refer the matter to the appropriate quality/safety individual, and/or interdisciplinary team, which shall, if appropriate, promptly plan and conduct an investigation. Depending on the nature of the incident, the investigation may involve departmental management, Employee Relations, the Coroner, and/or appropriate licensing and law enforcement agencies.

The investigation shall be conducted in accordance with all existing policies, including the Integrated Patient Safety Plan for those facilities covered by such plan. The investigation will determine the existence of system-based causes of adverse events. The investigation will include recommendations of potential improvements that would reduce the likelihood of similar adverse events.

Throughout the investigative process, all involved parties will treat the report and related information, including but not limited to information gathered and prepared in the course of the investigation of the incident, as confidential unless otherwise necessary to conduct the investigation. Any disclosure of information shall be done in such a manner as to not violate state or federal laws regulating the privacy of protected health care information.

At the conclusion of the investigation, the Director of the Health System, or his/her designee, will take the necessary steps to address the incident, including any necessary systemic changes to minimize or prevent reoccurrence of any such incident. The Director of the Health System, or his/her designee, shall also notify the person who filed the report that investigation has been completed.

(Ord. 4324, 08/15/06: Ord. 4438, 09/09/08)