Occurrences and Corrective Actions

An occurrence is an event that does not conform to the healthcare institution's policies and/or procedures and therefore has affected (or has the potential to affect) patient or employee safety. Occurrences need to be addressed. Therefore, open and trusted communication is vital for occurrence reporting and intervention to take place.

CLSI refers to corrective actions as actions "to eliminate the cause of a detected nonconformity or other undesirable situation."⁹ Corrective actions must be taken and documented to prevent a recurrence. Healthcare facilities usually have a specific process and form for this purpose. The form may be called an "occurrence report," "nonconforming event report," "incident report," etc. This report usually contains the who, what, where, when, why, and how of the occurrence. A full investigation may include the workers, quality manager, supervisors, and management. Facts must be reported; avoid opinions, biased comments, and emotions when completing this report.

Health care workers should understand that reporting the occurrence will result in better patient care and process improvement opportunities and should accept their role in the correction process. Being willing to report occurrences honestly and faithfully will benefit everyone in the long run.