Standards › Standard 1 › Policies
Policy · INC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 1.11
1. Purpose
To record, investigate and learn from incidents, so that harm is reduced and patients and staff are protected [E-006, EC].
2. Scope
All incidents affecting patients, staff, visitors, equipment, data or the building at the facility.
3. Responsibilities
| Role | Responsibility |
|---|---|
| quality lead | Reviews every incident and keeps the incident log. |
| risk manager | Scores risk and tracks corrective actions. |
| ward or department head | Reports within 24 hours and starts immediate action. |
4. Procedure
- Make the scene safe and give immediate care. Report the incident verbally to the ward head at once [EC].
- Complete the incident report within 24 hours [E-006].
- Quality lead logs the incident and grades harm and risk [EC].
- Investigate serious incidents with a root-cause review within 45 days [EC].
- Tell the patient or family and record the disclosure (see the disclosure procedure) [EC].
- Share the lesson learned with the team and check the action is done [EC].
5. Records
Incident report, incident log, investigation report, action log (kept for the period set by the facility’s records policy years).
6. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. |
| E-009 | ASF Expert Committee consensus. Timeframes are EC decisions. |
7. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | — | First approved version | Approved by the ASF Expert Committee |
E-learning for this document
- Incident Reporting, Just Culture and Open Disclosure (T-09)
- Records, Confidentiality and Data Protection (T-11)
- Complaints Handling and Patient Feedback (T-12)
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)