ASF Serious Incident Learning System
A voluntary, anonymised system for accredited facilities to report serious safety events, so the whole network learns from what any one facility discovers the hard way.
Framework established September 2026 · First public bulletin: once sufficient volume is reported
Where this stands today: the reporting definition, process, and confidentiality protections below are live now, from your first accreditation cycle. ASF does not yet have enough facilities reporting to publish a meaningful aggregate bulletin — publishing one from a handful of reports would imply patterns that don’t yet exist. The bulletin follows the data honestly, the same discipline as the Indicator Programme.
What Counts as a Serious Incident
| Category | Examples |
|---|---|
| Death or permanent harm unrelated to the natural course of the patient’s condition | Wrong-site surgery, medication error causing death, unexpected death in a low-risk procedure |
| Severe temporary harm requiring significant additional treatment | Retained surgical item, severe allergic reaction from a known, documented allergy |
| A near-miss with high potential severity | A wrong-site surgery caught at the final safety checklist, a medication error caught before administration |
| A systemic failure exposed by any of the above | An equipment failure, a communication breakdown, a staffing gap that directly enabled the event |
How Reporting Works
- Voluntary, not mandatory — reporting is encouraged, not required, and reporting a serious incident is never itself treated as a mark against a facility’s accreditation status.
- Reported through the Coordinator, using the same Incident Report Form structure (Annex C of the Annexes and Forms) already used for internal ASF matters, adapted for facility-level events.
- Anonymised before any aggregation — a facility’s identity is never included in any public bulletin or report without its explicit written consent.
- Reviewed by the Standards & Accreditation Committee, which identifies whether an incident reflects a gap the Standards themselves should address in the next revision cycle.
What ASF Does With a Report
- Acknowledges receipt within 5 working days.
- Reviews whether the contributing factors point to a standards gap, a training gap, or a facility-specific issue.
- Where a standards gap is identified, raises it through the normal Standards Development public comment process.
- Contributes the anonymised event to the aggregate dataset for the future public bulletin.
The Public Bulletin
Once reporting volume supports it, ASF will publish a periodic bulletin: aggregate, anonymised, categorised by event type and facility type, with the contributing factors and recommended safeguards — the same model as JCI’s Sentinel Event Alert or HAS France’s EIGS analyses, adapted to ASF’s scale. This page is the public commitment that the system exists and is already running, even before the first bulletin is ready to publish.
See the Incident Report Form (Annex C)
See the Indicator Programme
