ADMINISTRATION MANUAL TITLE: INCIDENT REPORTING AND INVESTIGATING POLICY #: SJ-09-01-30 SECTION: Occupational Health & Safety Services (OHS) ISSUING AUTHORITY: Senior Leadership Team ORIGINAL DATE APPROVED: April 2005 SUBSEQUENT APPROVAL DATES: November 2015 PURPOSE: To provide direction and guidance for obtaining immediate assistance, reporting and investigating work-related s and injuries including critical injuries, occupational illness, disabling and non-disabling injuries as outlined in the Occupational Health and Safety Act (OHSA). POLICY: St. Joseph s Health Centre (SJHC) is committed to providing a safe, healthy and supportive working environment and the prevention of workplace s and injuries. Once a workplace is reported, SJHC will investigate the appropriately to identify any control measures and improvements to reduce the likelihood of recurrence while working to meet all internal and external reporting requirements This policy applies to all s involving employees, purchased service contract workers, students, physicians, dentists, fellows, residents, midwives, RN-EC, and volunteers. ROLES AND RESPONSIBILITIES Employees Immediately report all workplace s, illnesses, near misses and hazardous conditions to their immediate Supervisor, Manager and/or Director Seek immediate medical attention when required Complete an Employee Incident Report (Appendix A) Report to Occupational Health and Safety Services (OHS) on the same day or next business day Participate in the investigation process Participate in the implementation of any control measures and/or improvement opportunities Supervisor/Managers/Directors Ensure an Employee Incident Report is completed and returned to OHS within 24 hours of the date the. Late reporting to OHS and the Workplace Safety Insurance Board can result in monetary penalty to the 1
Health Centre Immediately investigate all reported s, near misses and hazards to determine the root cause(s) and identify opportunities for improvement Complete appropriate Employee Incident Investigation Report (Appendix B/C/D) and return to OHS within the reporting timelines outlined in Appendix E Implement improvement opportunities to prevent reoccurrence and notify employee(s) and OHS when complete Notify OHS if an employee is absent from work for one (1) day following an via the online Employee Sick Absence Form Occupational Health & Safety Services (OHS) Provide support to employees following a workplace or injury including the provision of first aid Classify the reported for the purposes of reporting and investigation. Classifications of s include: o Critical Injury; o Occupational Illness o Disabling Injury; o Non-Disabling Injury o Near Miss / Report of Workplace Hazard Provide notification of the Joint Health and Safety Committee (JHSC), Union, and Ministry of Labour (MOL) where required by the OHSA Provide notification of Workplace Safety Insurance Board (WSIB) following an where required by the Workplace Safety and Insurance Act (WSIA) where required Work collaboratively with Programs and Services to ensure Employee Incident Reports and Employee Incident Investigation Reports (Appendix A) are fully completed and submitted. Where the Employee Incident Investigation Reports are not fully completed and submitted within the identified timeframes, escalation through the Chain of Communication will be followed Assist Programs and Services in determining and implementing appropriate proper work practices Maintain statistical data on s and report to the JHSC and other committees as appropriate PROCEDURE Employee Response: Notify the Supervisor/Manager/After Hours Supervisor or designate immediately Seek medical attention, if necessary o Staff report to OHS during business hours (Mon-Fri, 0700 to 1600) o If after hours report to SJHC Emergency Department Complete an Employee Incident Report Form (Appendix A) as soon as able 2
If first aid was not obtained in OHS at the time of the report to OHS on the next business day Director, Manager or Designate Response: Ensure the immediate safety of the employee Identify and alert staff, who were not involved in the of the potential risk to ensure the safety of all staff Debriefing for those directly or indirectly involved Notify the next level of management as appropriate Notify OHS of the no later than the next business day Investigate the, gather evidence and take necessary corrective actions to prevent recurrence as outlined on the investigation report provided by OHS If patient involvement complete a safety report in RMPro Ensure involvement of all appropriate individuals, which may include Human Recourses (HR), OHS, Patient Safety, Inter-professional Practice, Security, Medical Affairs and Enterprise Risk Management In the Event of a Fatality or Critical Injury Provide immediate medical aid for an injury Initiate a Code Blue, dial 9-911 if in the Sunnyside Building, Community Renal Centre or Urban Family Health Team Contact OHS, Manager, Supervisor/Manager/After Hours Supervisor and Security Services immediately Take measures to prevent others from exposure to the hazard Secure and preserve the scene No person can alter the scene without the permission of the MOL Inspector. This does not apply if it is necessary to disturb the scene in order to save a life or relieve human suffering. Document details of the original scene as soon as possible Obtain witness contact information and statements as soon as possible OHS will notify the MOL and JHSC Management and Worker members and WSIB A MOL Inspector and JHSC Worker member will be involved in a thorough investigation together A written report must be prepared and forwarded to the Ministry of Labour within 48 hours (Appendix B) Incident Investigation: The Director/Manager is responsible for conducting an investigation relying on familiarity with the staff member and department/program processes. The Director/Manager will include involvement of all appropriate individuals in the investigation process which may include Human Resources (HR), Occupational Health & Safety, Security Services, Medical Affairs, Patient Safety and Enterprise Risk Management, Senior Leadership Team. 3
The investigation must take place as soon as possible after the and must be completed within the reporting timelines outlined in Appendix E. This time line may be shortened based on the level of risk. Identifying the contributing factors will include direct observations and interviews with the injured employee and any witnesses. A statement from the injured person may be collected at a later date if they are unable to provide a statement immediately All investigations must be documented on the Employee Incident Report or Incident Investigation Report (Appendix A) as required and submitted to OHS within the designated time line Once the investigation has been completed and recommendations have been made, the appropriate management staff will inform all parties involved. Completed Employee Incident Investigation Report s will be provided to the JHSC, trade unions and regulatory agencies as required under the regulations The Chain of Communication will be followed for all Employee Incident Investigation Reports not completed and returned to OHS within the investigation time lines as outlined in Appendix E DEFINITIONS Critical Injury As defined in the Occupational Health and Safety Act critically injured means an injury of a serious nature that: (a) places life in jeopardy (b) produces unconsciousness (c) results in substantial loss of blood (d) involves the fracture of a leg or arm but not a finger or toe (e) involves the amputation of a leg, arm, hand or foot but not a finger or toe (f) consists of burns to a major portion of the body (g) causes the loss of sight in an eye Disabling Injury An, explosion, fire, or of workplace violence that causes injury to a worker and disables the worker from performing his or her usual work. Occupational Illness A condition that results from exposure in the workplace to a physical, chemical or biological agent to the extent that the normal physiological mechanisms are affected and the health of the worker is impaired. Physical Agents may include heat, cold, light, vibration, noise and radiation 4
Chemical Agents may include substances such as battery acid, solvents, ammonia and pesticides. Biological Agents may include organisms such as bacteria, viruses, fungus, parasites, spores and moulds Non-disabling Injury An where an employee seeks first aid or medical attention but does not miss work following the day of the it is considered a non-disabling injury. Hazard Potential or actual circumstances, equipment or process that could cause injury, illness or damage. Near Miss An unplanned event that did not result in injury, illness or damage but had the potential to do so. First Aid Includes but not limited to cleaning minor cuts, scrapes or scratches, treating a minor burn, applying bandages and/or dressing, cold compress, cold pack, ice bag, splint, changing a bandage or dressing after a follow-up observation visit and any follow up for observation purposes only. Example: An employee has a dressing applied to a minor cut by the Occupational Health Nurse. Health Care/Medical Aid An injury/illness that results in attention received from a recognized health care provider and does not result in time away form scheduled work and/or wage loss. Example: An employee goes to the Emergency Department for assessment and treatment of a back strain sustained at work. Lost Time A work related injury/illness that results in the employee missing scheduled time from work resulting in wage loss. Work hours lost on the day of the is not considered a lost time. REFERENCES: Ministry of Labour, Health and Safety Website, Workplace Safety and Insurance Board Website, Public Services Health & Safety Association Guidance Note for Workplace Parties #6, Occupational Injury and Illness Reporting Requirements CROSS REFERENCE: Return to Work from a Work or Non-Work Related Illness or Injury, SJ-09-02-01, Chain of Communication SJ 04-01-01, Management of a Critical Event/Incident QCIPA, SJ 03-03-06 REGULATORY REFERENCE: Occupational Health and Safety Act R.S.O. 1990, Regulation 834 Critical Injury Defined, R.R.O. 1990, Workplace Safety and Insurance Act, S.O. 1997, the Criminal Code of Canada R.S. 1985 DEVELOPED BY: Occupational Health & Safety REVIEWED BY: Joint Health and Safety Committee, Operations Committee, Senior Leadership Team DISTRIBUTION: Everyone 5
Appendix A EMPLOYEE INCIDENT INVESTIGATION REPORT 6
APPENDIX B MINISTRY OF LABOUR NOTIFICATION OF CRITICAL INJURY A. Name and Address of employer B. Nature and circumstances of the occurrence and the bodily injury sustained C. Description of the machinery involved, if any D. Time and place of the occurrence E. Name and address of the person who was critically injured or killed 7
APPENDIX B MINISTORY OF LABOUR NOTIFICATION OF CRITICAL INJURY(continued) F. Names and addresses of all witnesses to the occurrence G. Name and address of the physician or surgeon, if any, who is attending to or attended to the injured or deceased person H. Steps taken to prevent a further recurrence 8
APPENDIX C MINISTRY OF LABOUR NOTIFICATION OF OCCUPATIONAL ILLNESS A. Name and Address of employer B. Nature of the occupational illness and the circumstances which gave rise to such illness C. Description of the cause or the suspected cause of the occupational illness D. Period when the worker was affected 9
APPENDIX C MINISTRY OF LABOUR NOTIFICATION OF OCCUPATIONAL ILLNESS (continued) E. Name and address of the worker who is suffering from the occupational illness F. Name and address of the physician or surgeon, if any, who is attending to or attended to the worker for the illness G. Steps taken to prevent a further illness O. Reg. 67/93, s. 5. 10
APPENDIX D NOTIFICATION OF DISABLING INJURY A. Name and Address of Employer B. Nature and circumstances of the occurrence and the bodily injury sustained by the worker C. Description of the machinery or thing involved, if any D. Time and place of the occurrence E. Name and address of the worker who was injured 11
APPENDIX D NOTIFICATION OF DISABLING INJURY (continued) F. Names and addresses of all witnesses to the occurrence G. Name and address of the physician or surgeon, if any, who is attending to or attended to the worker for the injury H. Steps taken to prevent a further recurrence 12
APPENDIX E Incident Reporting and Investigation Timelines Type of Incident Occupational Health and Safety Act Requirement Occupational Health and Safety Act Interpretation Workplace Safety Insurance Act Requirement Workplace Safety Insurance Act Interpretation SJHC Employee Incident Form SJHC Employee Incident Investigation Form Death or Critical Injury Section 51.(1) immediately of the occurrence by telephone, telegram or other direct means and the employer shall, within forty-eight hours after the occurrence, send to a Director a written report of the circumstances of the occurrence containing such information and particulars as the regulations prescribe. Immediate notification by SJHC and completion of required report within 48 hours after learning of the. Section 21. (1) An employer shall notify the Board within three days after learning of an accident to a worker employed by him, her or it if the accident necessitates health care or results in the worker not being able to earn full wages. Completion of required WSIB Form by SJHC within 3 business days after learning of the Completed and received by OHS within 24 hours of the Completed and received by OHS within 24 hours of the. Occupational Illness or an Occupational Illness claim has been reported to WSIB Section 51.(2) notice in writing, within four days of being so advised, to a Director, to the committee or a health and safety representative and to the trade union, if any, containing such information and particulars as are prescribed. R.S.O. 1990, c. O.1, s. 52 (2); 1997, c. 16, s. 2 (12). Notification and completion of required report within 4 business days after learning of Section 21. (1) An employer shall notify the Board within three days after learning of an accident to a worker employed by him, her or it if the accident necessitates health care or results in the worker not being able to earn full wages. Completion of required WSIB Form by SJHC within 3 business days after learning of the Completed and received by OHS within 24 hours of the Completed and received by OHS within 3 business days of the 13
Type of Incident Occupational Health and Safety Act Requirement Occupational Health and Safety Act Interpretation Workplace Safety Insurance Act Requirement Workplace Safety Insurance Act Interpretation SJHC Employee Incident Form SJHC Employee Incident Investigation Form Disabling Injury Section 52.(1) within four days of the occurrence, give written notice of the occurrence containing the prescribed information and particulars to the following: 1. The committee, the health and safety representative and the trade union, if any. Notification and completion of required report within 4 business days after learning of Notification of the Ministry of Labour is not required, unless by Order of an Inspector. Section 21. (1) An employer shall notify the Board within three days after learning of an accident to a worker employed by him, her or it if the accident necessitates health care or results in the worker not being able to earn full wages. Completion of required WSIB Form by SJHC within 3 business days after learning of the Completed and received by OHS within 24 hours of the Completed and received by OHS within 3 business days of the Non- Disabling Injury or report of hazard/nearmiss 2. The Director, if an inspector requires notification of the Director. Not required. No action required. Not Required. No action required. Completed and received by OHS within 24 hours of the Completed and received by OHS within 5 business days of the 14