Office of Mental Health (OMH) operated and licensed providers must have an incident management system that protects the health and safety of consumers and improves quality of care. Our Critical Risk Management team works collaboratively with providers towards this goal. The primary risk reduction functions include:

Incident Management

A major component of Clinical Risk Management is the identification and management of adverse events (incidents). Our team reviews and follows up on serious incidents occurring in State operated and licensed programs each year. Follow up includes:

• phone or e-mail inquiries
• technical assistance
• investigation reviews
• on-site investigations and site visits

Training and OMH Correspondence to the Field

We conduct training sessions in each region of the state for both State operated and State licensed programs on an annual basis.

• In Person Fall 2024 Incident Investigation Training Announcement
• Online Special Investigation Training Registration
• Revised OMH Incident Regulations, Effective September 2015
• Security Personnel, Safety Officer, and Peace Officer involvement in OMH-licensed and operated CPEP and inpatient programs
• Part 524 Regulations and Reportability-recorded training
• Part 524 Regulations and Reportability-printable slides

Sentinel Events

Sentinel Events are unexpected incidents that involves death or serious physical injury. We provide oversight and technical assistance through the sentinel events review process. Our staff review and track root cause analyses and associated corrective action plans.

The goal is to assure a thorough and credible review that results in the implementation and monitoring of adequate and appropriate risk reduction strategies.

Special Investigations

Our team conducts special investigations in response to exceptionally serious incidents. The goal of an investigation is to determine and mitigate the underlying systemic factors associated with the adverse event.

Guidelines for Investigation of Significant Incidents in OMH Facilities

Comments or questions about the information on this page can be directed to the Office of Quality Improvement.