Introduction
Purpose
This policy establishes requirements for reporting, documenting, reviewing, correcting, and maintaining records of incidents associated with Adams School of Dentistry (ASOD) operations. The policy supports timely response, appropriate notification, consistent review, accurate records, and organizational follow-up.
The ASOD Incident Reporting App serves as the approved system for submitting incident reports, delivering incident specific guidance, routing reports to responsible reviewers, maintaining supporting documentation, and recording corrections or supplemental information. Incident reporting does not replace emergency response, patient record documentation, employee health reporting, privacy reporting, workers’ compensation requirements, or other processes required by law or University policy.
Scope
This policy applies to ASOD faculty, staff, adjunct faculty, residents, learners, affiliates, volunteers, contractors, and other individuals participating in ASOD operations. The policy applies to reportable events involving patients, visitors, personnel, learners, facilities, equipment, information, or ASOD activities.
Definitions
| Assigned Reviewer |
Individual responsible for evaluating, routing, documenting, and closing an incident report within their assigned area of responsibility. |
| Incident |
An event, condition, action, or omission that caused or could have caused injury, illness, harm, property damage, information exposure, disruption of operations, or another adverse outcome. |
| Incident Report |
Official administrative record submitted through the ASOD Incident Reporting App to document and support review of a reportable event. |
| Incident Reporting App |
ASOD electronic system used to submit, route, review, correct, supplement, and maintain incident reports and related documentation. |
| Near Miss |
An event that did not result in harm but had the potential to cause injury, illness, damage, loss, or disruption. |
| Point of Contact |
Individual or unit identified to receive notice of an incident or assist with response, review, or follow up. |
| Reporter |
Individual who submits an incident report or provides information for its submission. |
| Supporting Documentation |
Forms, records, photographs, correspondence, or other materials related to an incident and necessary for review or follow up. |
| Ticket |
Electronic review record generated from an incident report and assigned to a reviewer for action and closure. |
Reportable Events and Immediate Response
ASOD personnel must report events connected to ASOD operations that caused or could reasonably have caused injury, illness, harm, property damage, information exposure, interruption of treatment, operational disruption, or another adverse outcome.
Reportable events may include medical emergencies, sharps or bloodborne pathogen exposures, swallowed or aspirated objects, injuries, accidents, near misses, patient or visitor concerns, privacy or information security concerns, equipment or material failures, treatment related events, property damage, and other safety or operational concerns. Uncertainty about whether an event qualifies as an incident should not prevent reporting. Guidance is available through the ASOD Incident Reporting App or ASOD Clinical Compliance.
Safety, emergency care, patient care, and protective actions take priority over administrative reporting. Personnel must stop unsafe activity, address immediate hazards, obtain appropriate assistance, and notify supervising faculty, clinical leadership, a supervisor, or another responsible individual as applicable.
Submission of an incident report does not activate emergency services or replace direct notification to the ASOD Medical Emergency Team, emergency medical services, Campus Health, University Employee Occupational Health Clinic, UNC Privacy Office, Information Security, law enforcement, or another responsible office.
Reporting Responsibility and Submission
Reporting Responsibility
An individual directly involved in or witnessing an incident should submit the report when able. A responsible provider, supervising faculty member, supervisor, preceptor, program representative, or other authorized person with sufficient knowledge may submit the report when the directly involved individual cannot do so.
Assignment of reporting duties to another person does not transfer responsibility for immediate care, clinical documentation, required notification, or follow up. ASOD Clinical Compliance may complete or facilitate a report when no appropriate reporter is available, delayed administrative entry is necessary, or a technical issue prevents direct submission.
Submission Method and Timeframe
Incident reports must be submitted through the ASOD Incident Reporting App: https://go.unc.edu/asod-incident-report.
Reports must be submitted as soon as immediate safety and care needs permit and no later than 24 hours after the incident. Technical submission limits within the app do not extend the 24-hour reporting requirement. Incidents that cannot be submitted directly because of age, access restrictions, or system limitations must be reported promptly to ASOD Clinical Compliance through an approved alternative process. Delayed reports must include the reason for delay when known.
Required Information
Reporters must follow the guided questions and provide information relevant to the incident. Information may include:
- Date, time, and location;
- Individuals involved;
- Incident category and subtype;
- Objective description of what occurred;
- Immediate actions taken;
- Known injuries, effects, or outcomes;
- Individuals or offices notified;
- Relevant contact information; and
- Supporting documentation or follow-up known at the time of submission.
Reports must contain factual, objective, and relevant information. Observed facts must be distinguished from assumptions, opinions, or information received from others. Unrelated personal information, speculation, blame, and conclusions outside the reporter’s authority must not be included.
Routing, Notification, and Follow-Up
ASOD Incident Reporting App routes submissions based on the incident category, location, individuals involved, and other reported information. Routing may notify an assigned reviewer, department representative, supervisor, preceptor, program leader, ASOD Clinical Compliance, or another responsible office.
Automated routing supports but does not replace direct notification required by law, University policy, ASOD policy or procedure, or professional responsibility.
Submission confirmation identifies the assigned point of contact or reviewer when applicable and provides summary guidance. Additional instructions may be delivered through email and may include forms, maps, health resources, escalation requirements, or other incident-specific actions. Reporters must follow applicable guidance and monitor the email address provided for additional instructions or requests. Current forms, maps, guides, and related resources are maintained through the ASOD Incident Reporting App’s documentation area. Personnel must use the current version available through the approved system. Additional reporting or documentation may also be required through another office or system. Examples include patient record documentation, employee or learner health reporting, workers’ compensation, privacy reporting, information security notification, equipment servicing, or other institutional processes.
Supporting Documentation, Corrections, and Supplemental Information
Supporting Documentation
Supporting documentation must be added to the corresponding incident report when required or relevant to review. Reporter or responsible individual must upload documentation promptly after it becomes available. Documentation may include:
- Medical Emergency Response Records;
- Lab, radiology, or health care forms;
- Informed refusal forms;
- Photographs or equipment information;
- Relevant correspondence;
- Follow-up findings;
- Corrective-action records; or
- Other materials requested by the assigned reviewer or ASOD Clinical Compliance.
Responsible individuals must upload documentation promptly after it becomes available. Uploads must be completed through the ASOD Incident Reporting App whenever that function is available. Email may be used only when the app cannot accept the documentation or ASOD Clinical Compliance provides alternate instructions. Sensitive information must be submitted through approved systems and limited to information necessary for care, reporting, review, investigation, or follow-up.
Corrections and Supplemental Information
Authorized users may correct limited information, append clarification, or upload supporting documentation through the ASOD Incident Reporting App. Corrections must preserve the integrity of the original submission and must not conceal, delete, or materially misrepresent previously reported information.
Supplemental entries should identify the new or corrected information, reason for the change, and date the information became known when relevant. App access may be limited according to the individual’s role, relationship to the report, assigned department, ticket status, and age of the incident. Current functionality generally permits corrections and uploads for reports with an open ticket and within 90 days of submission, subject to applicable access rights.
Requests outside the available correction period must be directed to ASOD Clinical Compliance. Administrative review may result in an update, supplemental entry, reopened record, or another approved method of preserving the information. Reporters and responsible units must correct inaccurate information and provide material follow up when an error or omission is identified. Assigned reviewers may request clarification, correction, or additional documentation needed to complete the review.
Other Required Records
ASOD Incident Reporting App does not replace documentation required in a patient health record, employee health record, learner health record, workers’ compensation file, privacy record, equipment-maintenance record, or another official system. Responsibility for completing those records remains with the person or unit accountable for the underlying activity.
Incident Review and Resolution
Assignment and Review
Each submitted incident generates or supports an electronic ticket assigned to an appropriate reviewer. Assignment must reflect an operational, clinical, administrative, safety, privacy, compliance, or subject-matter relationship to the incident. Ticket assignment does not independently establish fault, responsibility, or authority outside the reviewer’s assigned role.
Assigned reviewers are expected to:
- Review the report and available documentation;
- Determine whether available information is sufficient;
- Request clarification or supporting records when needed;
- Coordinate follow up within their authority;
- Refer or reassign the ticket when another individual or unit is more appropriate;
- Reassignment transfers review ownership but does not close the ticket.
- Document relevant actions, findings, or process changes; and
- Select an appropriate disposition and close the ticket.
Review Dispositions
Available review outcomes may include:
| Review Complete |
Report was reviewed, necessary action was taken or documented, and no further ticket activity is required. |
| Not an Incident |
Submission was made in error, duplicated another report, did not describe an actionable incident, or is more appropriately managed as a question or service request. |
| Insufficient Data |
Critical information remained unavailable after reasonable follow-up, preventing a complete determination or review. |
Timeliness and Escalation
Assigned reviewers must evaluate reports according to incident severity, urgency, and applicable requirements. Active safety risks, medical concerns, privacy or security issues, regulatory obligations, and continuing operational hazards require prompt escalation. Necessary care, protective action, reporting, or follow up must not be delayed while awaiting ticket closure.
Corrective Action
Responsible units must evaluate identified hazards, process failures, or recurring concerns and implement corrective action within their authority. Corrective action may include education, equipment repair, workflow modification, policy or procedure review, environmental changes, additional monitoring, or referral to another office. Ticket closure does not prevent additional investigation, corrective action, disciplinary review, legal review, or regulatory reporting when required.
Access, Confidentiality, and Records Management
Access to incident reports must be limited according to a person’s role, involvement, department, assigned responsibilities, and legitimate business need. Authorized users may be permitted to view reports they submitted, reports associated with their department, or reports within their assigned oversight responsibilities. Certain users may also request or generate report copies through the approved app process. System access does not authorize disclosure, export, distribution, or use outside assigned duties.
Incident records may contain patient, learner, employee, personnel, operational, safety, privacy, or other sensitive information. Personnel must protect such information and use it only for authorized care, review, compliance, legal, safety, administrative, or operational purposes. Information must not be shared through unapproved channels or with individuals who lack an authorized need.