Incident review management: a systemic approach to performance improvements

J Healthc Qual. Nov-Dec 1999;21(6):21-7. doi: 10.1111/j.1945-1474.1999.tb01000.x.


Incident reporting has emerged as a cornerstone of sound quality improvement programs. Sentinel events, "a serious and undesirable occurrence involving the loss of life, limb, or function of an individual served" (Joint Commission on Accreditation of Healthcare Organizations, 1996), is a mandated indicator for Joint Commission standards of accreditation for audited healthcare facilities. Properly investigated and documented individual incidents can lead to systemic improvements, which may enhance the quality of client care and the integrity of the healthcare facility. This article proposes a systemic approach to the incident review (IR) process in long-term healthcare facilities. This comprehensive approach incorporates identification, investigation, and management of the IR process from the inception of a problem to the continued follow-up to ensure that improvement plans are effectively implemented.

MeSH terms

  • Communication
  • Forms and Records Control
  • Humans
  • New York City
  • Nursing Homes / organization & administration
  • Nursing Homes / standards*
  • Organizational Policy
  • Professional Staff Committees
  • Quality Assurance, Health Care / methods
  • Quality Assurance, Health Care / organization & administration*
  • Quality Indicators, Health Care
  • Risk Management / methods*
  • Sentinel Surveillance*