Incident reporting built for ambulatory surgery centers
Log transfers and near misses between cases, and meet surveyors with every loop closed.
Who reports, who signs
Pre-op, PACU, anesthesia and sterile processing staff report. The clinical director investigates, the administrator owns the fixes, and the governing body reviews the trend.
You answer to
SAMPLE RECORD · SYNTHETIC DATA
Where reporting breaks down.
Events live in four places
A transfer sits in the EHR, an email and a binder tab. Before committee, someone rebuilds the list by hand and misses the near misses.
Post-discharge events surface late
A next-day call finds a patient who went to the ED. CMS measures hospital visits from claims, long after your call log shows the pattern.
The loop has to close, and show it
42 CFR 416.43 asks you to track adverse events, find causes, improve and make it last. Signed forms prove only the first step.
Ten centers, ten vocabularies
One center logs a PACU fall as a slip, another as a safety event. The group's quality director cannot compare rates.
The incidents this pack is built for.
- Wrong-site, wrong-patient or wrong-procedure event
- Site-marking or laterality near miss
- Unplanned transfer to a hospital
- ED visit or admission after discharge
- Fall in pre-op, the OR or PACU
- Patient burn
- Anesthesia event
- Hypothermia on arrival to PACU
- Retained item or count discrepancy
- Medication error
- Sterile processing event
- Device or equipment malfunction
What you answer to.
- 42 CFR 416.43, ASC QAPI
- A data-driven program that tracks adverse patient events, finds causes, makes improvements and keeps them in place. Each project is documented with its reasons and results.
- 42 CFR 416.41(b), hospital transfer
- Have a working procedure to transfer patients who need emergency care you cannot give. Give the local hospital written notice of your operations.
- ASC Quality Reporting Program
- Web measures: burns (ASC-1), falls (ASC-2), wrong site, side, patient, procedure or implant (ASC-3), hospital transfer or admission (ASC-4). Missing them costs 2.0 percentage points off your annual payment update.
- AAAHC, Quad A and ACHC
- CMS-approved ASC accreditors. Each surveys your quality program. Quad A has required Patient Safety Data Reporting since 2001.
- The Joint Commission
- Wrong-site, wrong-patient or wrong-procedure surgery is a sentinel event whatever the outcome. A full analysis and action plan is expected within 45 business days. Reporting is encouraged, not required.
- 21 CFR 803.30, FDA device reports
- An ASC is a device user facility. Report a device-related death to FDA and the manufacturer, and a serious injury to the manufacturer, within 10 work days of becoming aware.
- State licensure and adverse event rules
- State rules apply on top of federal ones and differ by state. Check yours; routing and escalation can be set per center.
A laterality mismatch caught in pre-op
An example near miss, not a customer story.
01Report
Nurse catches mismatch, scans QR code
In pre-op, a nurse sees the consent says left knee but the site mark and schedule say right.
She holds the case and scans the QR code.
Lauren asks follow-ups, drafts report
Lauren asks whether the patient entered the OR, who marked the site, and which document was wrong.
The draft says “Lauren · draft”. The nurse signs.
Administrator and clinical director notified
The report is classed as a near miss with no harm.
The administrator and clinical director are told at once, and notice times are logged.
02Investigate
Clinical director opens the investigation
Lauren drafts likely causes: a consent from a stale scheduling template, and site marking before consent review.
The director edits, adds the five whys and signs.
03Correct
Three actions created, evidence required
Build consents from the booking record, add a consent-to-mark check to pre-op, and audit the next 30 time-outs.
Each action gets an owner, due date and evidence.
Audit sheets attached, actions close
The clinical director verifies the check and the actions close.
The audit sheets are attached as evidence, and the audit trail shows every step.
04Prove
QAPI committee reviews near misses
The QAPI packet lists near misses by type and location, with cause, actions and verification.
The committee records the project as sustained.
Surveyor asks, the record answers
The surveyor asks how the center tracks adverse events and shows improvements held.
The incident PDF and QAPI summary answer from the record.
Illustrative scenario. Details are invented to show how the workflow runs.
See this on your site.
Thirty minutes, built around your incidents, your regulator and the proof you have to produce.
Set up for your kind of site.
Forms, routing, exports and roles are configured per site. We load them for you on paid plans.
Forms
- ASC incident report
- Wrong site, patient or procedure event or near miss
- Unplanned transfer to a hospital
- Follow-up call log after discharge
- Anesthesia event form
- Fall form for pre-op, OR and PACU
- Burn event form
- Device event sheet for the FDA decision
Routing
- Wrong-site event or near miss: administrator and clinical director at once
- Unplanned transfer: clinical director and anesthesia lead, same day
- Device death or serious injury: administrator decides on the 10-work-day FDA report
- Possible sentinel event: administrator, medical director and governing body chair
- ED visit or admission after discharge: clinical director review
Exports
- QAPI summary packet for 42 CFR 416.43, one PDF
- Yearly CSV counts of burns, falls, wrong-site events and transfers, for HQR
- Incident PDF with investigation, actions and signatures
- Survey packet for AAAHC, Joint Commission, Quad A or ACHC (rolling out)
Roles
- Reporter: any nurse, technician or contract provider
- Editor: pre-op, PACU and sterile processing leads
- Supervisor: clinical and medical directors
- Admin: administrator, who owns the fixes
- Super admin: corporate quality director
- Viewer: governing body and consultants
Outcomes you can plan for.
A QAPI record that builds as events happen
Each event, cause and fix is logged as it happens. The QAPI summary needs no hand rebuild.
Near misses that count
A near miss is quick to log between cases. It joins the trend with harm events, so patterns show early.
You see post-discharge events first
A follow-up call log feeds the same record. ED visits and admissions show in your analytics before CMS's claims-based measures can.
One vocabulary across a group
Every center uses the same event types and definitions. Corporate can compare falls, transfers and wrong-site near misses by center and shift.
The rules behind this pack.
Surgery centers: frequently asked
Something we missed? Ask us, and a person answers.
What does 42 CFR 416.43 require an ASC to track?
An ongoing, data-driven QAPI program that tracks quality indicators, adverse patient events and infection control. You must find causes, improve and make the gains last, and document each project's reasons and results. See QAPI for ASCs.
Which ASC Quality Reporting Program measures are really incidents?
Four web-based measures count events: burn (ASC-1), fall (ASC-2), wrong site, side, patient, procedure or implant (ASC-3) and hospital transfer or admission (ASC-4). You submit through HQR; CY 2026 data is listed for January 1 to May 17, 2027 (confirm on QualityNet). ASCs with fewer than 240 Medicare fee-for-service claims a year need not participate. See ASCQR.
Does IncidentKit replace our EHR or submit to CMS?
No. IncidentKit runs alongside your EHR and scheduling system. It keeps the incident record and gives you the counts and packets; you still submit through HQR. A read API and signed webhooks are available now, and deeper EHR links are rolling out.
Does Lauren write the incident report?
No. Lauren asks the follow-up questions and drafts fields from what the reporter said. Every drafted field says “Lauren · draft” until a person reviews, edits and signs. Text intake works today; voice is rolling out.
How is it priced, and who built it?
Surgery centers use the per-site Regulated plan: a BAA, patient information, compliance packets and done-for-you setup, with no seats, modules or setup fee. Groups of 10 or more sites use custom Network pricing. PharmPro's compliance consulting practice built it: 31 years in survey and inspection prep, 250+ facilities taken through survey. See pricing.
See it on your site.
Tell us about your sites and we will build the demo on your kind of facility. Or start free and report something real today.