SAMPLE POLICY WORK

– The plan specifies responsible individuals, deadlines, and the expected outcomes for each corrective measure. 7. Implementation of Corrective Actions: – All intended corrective actions are promptly implemented, and changes are communicated via internal channels to all affected staff. – The corrective action plan is monitored continuously, using digital dashboards that track progress in real time. 8. Final Review and Incident Closure: – Once corrective measures have been implemented and verified, the incident is marked as “closed” in the SEIMS. – A final incident report is generated summarizing the entire investigation, corrective actions, and lessons learned. – The final report is stored in the central quality repository and becomes accessible during routine audits. 9. Feedback and Continuous Learning: – Post-incident debriefings gather insights and feedback from all involved. – Feedback is integrated into future training modules and reviewed through the QI Committee, with results communicated to the broader team through monthly quality newsletters.

Implementation Checklist

Responsible Party

Task

Frequency

Verification Method

Immediate notification of incident

All staff

Upon occurrence

Incident Report Form submission

Completion of the Incident Report Form

Reporting employee

Immediately; within 15 minutes for severe incidents, within 24 hours for others Simultaneously with report submission

Digital report logs in SEIMS

Escalation and notification to supervisors Initiation of preliminary investigation Conducting Root Cause Analysis

Direct supervisor

Automated system alerts and supervisor acknowledgment Meeting minutes, witness statements, digital logs Root Cause Analysis documentation, Fishbone diagrams Written corrective action plan with

Incident Response Team Designated Investigator

Within 15 minutes to 1 hour (depending on severity)

Within 24 hours

Development of corrective action

QI Committee

Within 48 hours