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Clinical Support Services

Adverse Events, Close Calls and Hazards

Clinically Serious Adverse Events

The moments following any serious event are emotional for all those involved. We have created job aids to enable staff and leaders closest to the event to coordinate their efforts, determine next steps, and speak to those involved with one voice. Please click here to access those resources.

412 Reporting

The Reporting & Learning System (RLS) is a quick and easy way for staff to document potential and actual patient safety issues (adverse events, close calls and hazards).  It is a provincial system used by both Alberta Health Services (AHS) and Covenant Health.

What's New?

Effective November 5, 2013

  • Entrance into the RLS reporter form will change from the current yes/no to one single button leading to the form.
  • All RLS reports will be shared with the managers of the area involved.
  • Reporters will have the option to keep their name confidential.
  • A new "Suggestion Box" allows reporters to communicate their ideas for making patient care safer.
  • Check out the poster.

Also effective November 5, 2013 the new elopement documentation section on the RLS went live!!  This new reporting section for elopement:

  • Is easy to use.
  • Records information specific to elopement to suport follow-up investigation.
  • Gathers information on these events to improve patient safety.
  • Check out the poster

When an adverse event, close call or hazard occurs, it is important to appropriately report the incident as there are both voluntary and mandatory reporting obligations within Covenant Health and with external agencies (eg. Health Canada). These obligations are outlined in our corporate policy, "Responding to Adverse Events, Close Calls and Hazards".

When you submit a report in the online RLS, you are calling attention to safety issues so that they can be addressed. This valuable information will be used to manage, prioritize, and address system improvements and prevent the event from happening again.

  • Access RLS  or call 1.877.338.3854.
  • Check out RLS Education & Training Resources.
  • Learn more about RLS.

If you know of any reportable events that are not included in the policy, please email or phone 780.735.2284.

List of Known Reportable Events

In addition to adverse events, close calls and hazards, there are many other types of events (eg. equipment malfunction) that need to be reported within Covenant Health and sometimes externally (eg. Health Canada). A table that outlines a list of known reportable events and required notification is included with the policy.

Government of Alberta - Reportable Incident Form

Health Canada – Adverse Drug Reaction Form

Health Canada – Narcotic Controlled Substances Discrepancy Reporting Form

413 Disclosing

When an adverse events occurs, health service providers need to ensure patients, residents and/or family have an understanding of what happened, what supports are available to them, next steps, and what will be done to ensure a similar event does not happen again. 

Patients, residents and substitute decision makers are entitled to an accurate understanding of their care.  Respecting patients/residents’ right to know about their care, along with trust and open communication, is essential to building and maintaining positive relationships.  By sharing and disclosing information in an open, honest and timely manner, collaborative and positive relationships with patients, residents and their families is promoted and developed

Close calls or hazards may be disclosed to the patient/resident or substitute decision makers based on clinical and professional judgment as to whether disclosure is in the patient/resident’s best interest and/or their expressed wishes.

Disclosure Process

Disclosure is an ongoing process in which multiple disclosure conversations may occur over time. The disclosure process involves the following five (5) steps:

It is important to prepare before any disclosure conversations, discuss only the facts known (avoid speculation), always disclose with another staff member present and to document all disclosure conversations in the patient/resident chart.

Disclosure Resources

Numerous resources are available to support staff throughout the disclosure process:

414 Investigating

Adverse events, close calls or hazards are opportunities to identify improvements in order to reduce the likelihood of future harm and prevent similar occurrence.

As part of its Just Culture, Covenant Health acknowledges that errors do occur and individuals should not be held accountable for system failures in which they had no control over. However, a Just Culture also acknowledges the need for professional accountability and has zero tolerance for reckless behaviour.

Thorough reviews of adverse events, close calls and hazards are considered one of the more effective approaches to improving patient safety. Where possible, lessons learned should be used to improve healthcare practices, processes and systems

Types of Reviews

Sometimes staff and leaders struggle with what type of review should take place.  Did the event occur because of a system issue or because of individual performance?  What about both?  What’s the most appropriate course of action to take? The Incident Decision Tree is a tool to help staff and leaders decide what review should take place following an adverse event, close call or hazard. The Options for Review algorithm helps to determinie the type of review required.

Operational Review

Also known as Fact Finding, should always be the first type of review completed. This type of review concentrates on looking at the facts and most often involves reviewing documentation on the clinical records. Reviewing the documented facts can often provide an answer to why something happened; however, sometimes factual information alone is not enough to fully understand “why” and “how". In these cases getting additional information, including interviews and opinions, is needed in order to better understand what happened which is part of a QAR. A template to assist in completing this fact finding process can be found here

Quality Assurance Review

Also known as a Root Cause Analysis, a Quality Assurance Review is conducted as part of the activities of a Quality Assurance Committee.  This type of review is privileged and confidential as it is protected by Section 9, Alberta Evidence Act. A Quality Assurance Review identifies system contributing factors that may have lead to the adverse event, close call or hazard, and focuses on system improvements.  It does not investigate the actions or behaviors of individual healthcare providers. 

If considering to complete a Quality Assurance Review, please contact the Covenant Health Quality & Patient Safety Office at or 780.735.2284.

Educational Case Review

Formerly known as M&M Rounds, the focus of this review is physician education.  Physicians can review cases for education purposes and make general recommendations.  Educational Case Reviews can be a method to screen cases to feed into the Quality Assurance Review process.  It is important to note that Educational Case Reviews are not protected by Section 9 of the Alberta Evidence Act.

Administrative Review

An Administrative Review is completed if there are individual performance issues involved (eg. concerns regarding competency, behaviour etc). Before completing an Administrative Review, consult with your local Human Resources department.

To learn more about the investigation process, please view the corporate policy and procedure Responding the Adverse Events, Close Calls and Hazards 418 QARs

Quality Assurance Reviews (QARs), which can include root cause analysis (RCA), allow for a safe and supportive environment where staff and physicians may share their opinions and brainstorm if the factual information available is not enough. This type of review involves conducting staff interviews in order to capture what may not be documented. QARs always result in the identification of improvements which are often based on the feedback and insight gained from staff interviews, and review of best practices, literature and standards.  

QARs are initiated, conducted and reviewed by Quality Assurance Committees (QACs) which exist in nearly all programs and facilities in Covenant Health. These committees review severe adverse events, such as an unexpected patient/resident death, but also look at less serious events particularly if there seems to be a pattern or trend. QACs do not review or discuss individual performance, but rather look at system improvements and seek to answer the question “what could have been done to prevent this?”.  

Many staff and physicians fear that by sharing their opinion it may be used against them, especially in legal proceedings. However, activities for a QAC, including QARs, are protected under Section 9 of the Alberta Evidence Act. This means that any conversations or activities that occur within a QAC meeting or as part of a QAR cannot be used in court. However, the recommendations resulting from a QAR are accessible and are often shared with staff, physicians, and other program areas or facilities to help prevent reoccurrence. Most importantly, QAR recommendations are shared with the patient, resident and/or their family.

There are a number of resources available, including for Quality Assurance Committees:

Quality Assurance Committee Handbook

Covenant Health Approved Quality Assurance Committees 

Quality Assurance Committee Terms of Reference Template

And for Quality Assurance Reviews:

Quality Assurance Review Process 

Quality Assurance Review Process Control Checklist 

Quality Assurance Review Document Control Checklist 

Quality Assurance Review: Request and Acceptance Form 

Quality Assurance Review Membership Form 

Quality Assurance Review Timeline Template  

Quality Assurance Review Report Cover Letter Template 

Quality Assurance Review Comprehensive Report Template 

Quality Assurance Review Concise Report Template 

Quality Assurance Review Recommendations Template 

Quality Assurance Review Action Plan Template