INCIDENT REPORTING POLICY AND PROCEDURE — TRAINEES & STUDENTS

INTRODUCTION

This policy explains how trainees and students at ELITE BODY HOME POLY CLINIC L.L.C must report incidents, near misses and unsafe conditions. It protects the health, safety and well being of students, staff, patients and visitors, ensures compliance with KHDA, DHA and CIDESCO guidance, and focuses on learning and preventing recurrence rather than blame.

PURPOSE

  • Encourage timely and consistent reporting of hazards, incidents and near misses.
  • Ensure incidents involving trainees and students are investigated and root causes addressed.
  • Ensure corrective and preventive actions (CAPA) are implemented and tracked.
  • Provide data to improve safety, training and regulatory compliance.

SCOPE

Applies to all trainees, students, instructors, clinical supervisors, clinical staff and support staff while on ELITE BODY HOME POLY CLINIC premises, during official clinical placements, training activities and affiliated external placements.

RESPONSIBILITIES

  • Trainees & Students: Immediately report any incident, near miss, unsafe condition or extreme/disruptive behaviour.
  • Instructors / Clinical Supervisors: Provide first aid/assistance, secure scene (if safe), preserve evidence, support the trainee/student, and notify the CEO or Program Director.
  • CEO or Program Director: Accountable for writing official incident reports, managing investigations, ensuring CAPA, escalating to regulators (KHDA/DHA/CIDESCO) when required, and maintaining records.
  • Medical Director / Clinical Staff: Provide and coordinate urgent medical assessment and care, advise on clinical aspects of investigations, and support fitness to practice evaluations as needed.
  • Completion of an Incident Report Form is for safety, learning and regulatory compliance and does not constitute an admission of liability.

KEY DEFINITIONS (for trainees)

  • Incident: Any event that did or could have caused unexpected or unintended harm, loss or damage.
  • Near miss: An event that could have caused harm but did not.
  • Adverse Event: An unexpected negative outcome or harm.
  • Sentinel Event: A serious unexpected event (e.g., death, major permanent harm).
  • Extreme behaviour: Behaviour posing immediate/foreseeable risk or significantly disrupting training (physical assault, credible threats, severe verbal aggression, intoxication, self harm attempts).
  • First Aid: Immediate basic treatment that allows return to normal duties.

WHAT TO REPORT

Report any event that could or did cause harm, including but not limited to:

  • Physical injury, exposures (sharps, chemical), allergic reactions, fainting.
  • Near misses and unsafe conditions (equipment faults, spills).
  • Extreme/disruptive behaviour, threats, violence, intoxication, self harm.
  • Property damage, fire, security incidents, or incidents involving patients/public.

Required information:

  • Exact location (room/unit/building)
  • Date and exact time
  • Names, roles and contact details of persons involved and witnesses (include student ID)
  • Name and contact details of person in charge at the time (instructor/supervisor)
  • Factual description of event (no opinions)
  • Immediate actions taken (first aid, isolation, equipment removed)
  • Nature of injuries or suspected injuries and property damage details
  • Evidence preserved (CCTV, photos, audio) where available
  • Legible signature or electronic submitter identity

REPORTING TIMEFRAMES & PROCESS

  • If life threatening or posing immediate risk: call emergency services (ambulance/police) and Security immediately; clinical staff provide urgent care.
  • Notify your instructor/clinical supervisor immediately. Instructor/supervisor must notify the CEO or Program Director as soon as possible (phone/text).
  • Formal Incident Report submission deadlines:
    • Serious / Adverse / Sentinel incidents: Notify CEO or Program Director immediately by phone and submit the Incident Report within 24 hours.
    • Non serious incidents: Submit the formal Incident Report within 3 working days of the event.
  • If electronic reporting is unavailable, initial communication must be via phone or email; follow up with the formal report when possible.

HOW TO REPORT — STEP BY STEP (for trainees/students)

  1. Ensure safety and provide/seek first aid for injured persons.
  2. Alert instructor/clinical supervisor and Security (if required).
  3. Secure scene if safe — prevent further harm and preserve evidence.
  4. Record immediate facts (who, what, when, where) in writing.
  5. Complete the ELITE BODY HOME POLY CLINIC Incident Report Form (student version) and submit to your instructor/supervisor.
    • For serious incidents: notify CEO or Program Director immediately and submit within 24 hours.
    • For non serious incidents: submit within 3 working days.
  6. Instructor/supervisor alerts the CEO or Program Director.
  7. Cooperate with investigation and follow any interim measures.

BEHAVIOURAL & EXTREME BEHAVIOUR INCIDENTS (students)

  • Immediate actions: ensure safety, call emergency services if necessary, isolate the individual if safe (do not restrain unless trained and required), and provide urgent medical/psychological care as needed. The Medical Director coordinates medical response.
  • Reporting: immediate verbal notification to instructor/clinical supervisor and CEO or Program Director at the time of the incident. Complete the Incident Report and Behaviour Incident Addendum:
    • Serious behavioural incidents (assault, self harm needing emergency care, police involvement): initial notification immediately and formal report within 24 hours.
    • Non serious behavioural incidents: formal report within 3 working days.
  • Interim measures (pending investigation) may include temporary suspension from clinical duties, restricted campus access, or supervised return; the CEO or Program Director authorises and documents these measures.

INVESTIGATION & ASSESSMENT

The CEO or Program Director leads the administrative investigation and produces the official report; an investigation team may be appointed including instructors, clinical staff and Student Affairs representatives. The Medical Director provides clinical input.

Investigation steps:

  1. Preliminary triage and risk assessment (within 24–72 hours for serious incidents).
  2. Gather statements, preserve and review evidence (CCTV, records).
  3. Perform root cause analysis (identify human, process, equipment, organizational factors).
  4. Recommend CAPA, assign responsibilities and timeframes.
  5. Produce final incident report (recommended within 7–14 days for typical cases; complex cases may require longer).

Investigations focus on systems and learning, not individual blame.

CORRECTIVE & PREVENTIVE ACTIONS (CAPA)

  • CAPA must be SMART (Specific, Measurable, Achievable, Relevant, Time bound).
  • CEO or Program Director ensures CAPA are assigned, tracked and closed.
  • Trainees/students may be required to participate in remedial training, counselling or supervised practice as part of CAPA.
  • CAPA outcomes and lessons learned are shared (anonymized) with relevant staff and students.

PROTECTIVE & INTERIM MEASURES

  • Interim safety measures (temporary suspension from placement, restricted access, supervision) may be implemented to protect safety pending investigation.
  • Interim measures must be documented in writing with rationale and duration, balancing safety and fairness.

DISCIPLINARY PROCESS, HEARING COMMITTEE & LEGAL INVOLVEMENT

  • Once an incident of behavioural misconduct is recorded, the institution’s Disciplinary Policy (attached) applies in full.
  • The matter will be referred to the Hearing Committee (or Student Disciplinary Hearing Committee) for adjudication. The Hearing Committee will:
    • Review the incident report, Behaviour Incident Addendum, investigation findings and supporting evidence.
    • Conduct a hearing following the attached Disciplinary Policy procedures (notice of hearing, opportunity to respond, representation rights, evidence review).
    • Determine and impose appropriate sanctions in accordance with the Disciplinary Policy (e.g., warning, behavioural contract, mandatory counselling, probation, suspension, expulsion).
    • Document the decision, rationale and right of appeal, and communicate outcomes in writing to involved parties.
  • At times, based on clear and undisputed findings, the Disciplinary Committee may issue a direct warning without convening a formal hearing.
  • The CEO or Program Director coordinates the referral to the Hearing Committee, provides the official incident report, and ensures interim safety measures are applied pending the hearing if required.
  • Criminal matters will be reported to law enforcement; CEO or Program Director coordinates external reporting and legal liaison.

CONFIDENTIALITY & NON RETALIATION

  • Incident reports, investigations and disciplinary proceedings are confidential and shared only with those who have a legitimate need to know.
  • Reports made in good faith are protected from retaliation.

RECORDKEEPING, AUDIT & REGULATORY REPORTING

CEO or Program Director ensures retention of incident and disciplinary records in a secure system and makes them available for audits and regulator inspection (KHDA, DHA, CIDESCO) as required.

CEO or Program Director is responsible for timely escalation to regulators per regulatory thresholds and timelines.

TRAINING & PREVENTION

  • Mandatory training for students and staff: de escalation, conflict management, emergency response, infection prevention, sharps safety and mental health awareness.
  • Behaviour expectations and reporting procedures must be included in student orientation and handbook.
  • Regular drills and reviews to test readiness and response.

COMMUNICATION & LEARNING

  • Anonymized lessons learned and safety bulletins are shared with staff and students.
  • Support and counselling services are offered to affected persons and educational or placement adjustments made as appropriate.

APPENDIX (to be attached)

  • Student Incident Report Form (fields: student name, student ID, course, instructor, location, date/time, witnesses, factual account, immediate actions, injuries, evidence preserved, severity, submitter signature, date).
  • Behaviour Incident Addendum (fields for narrative of behaviour, witness statements, evidence checklist, interim measures).
  • Disciplinary Policy (attached) — governs hearings and sanctions.
  • Quick response checklist for instructors/supervisors (emergency numbers, CEO/Program Director contact details, immediate actions).
  • CAPA template and investigation checklist.
  • Interim safety notice template (for suspension/restriction).
  • Referral form for counselling and mental health services.
  • One page poster: “If you witness an incident — 6 steps to safety” for placement and training areas.

REFERENCES

  • KHDA regulations applicable to training institutes
  • DHA Health Care Standards – April 2022
  • CIDESCO professional and safety guidelines
  • Local public health and safety orders