Applicable to : Acute care/Transitional Care Sites/Personal Care Homes

Follow-up/Update from previous Call to Action dated May 31, 2021.

The following update is to provide clarity on occurrence reporting completion related to COVID-19:

For any Patient/Resident who has a confirmed COVID-19 Health Care Acquired Infection deemed by Infection Prevention & Control no longer requires an occurrence report to be completed. COVID-19 is now considered a risk inherent, when receiving health care services, due to the transmissibility and degree of community spread of the virus. However, a Critical Incident (CI) may still be declared if there are circumstances such as system issues that were not mitigated to the greatest extent possible.  

Follow these steps to determine if a COVID-19 HAI is a Critical Incident:

A critical incident is an unintended event that occurs when health services are provided to an individual and results in a consequence to him or her that:

1. Is serious and undesired, such as death, disability, injury or harm, unplanned admission to hospital or unusual extension of a hospital stay AND
2. Does not result from the individual's underlying health condition or from a risk inherent in providing the health services.

NOTE: “COVID- 19 is now considered a risk inherent, when receiving healthcare services, due to the transmissibility and degree of community spread of the virus”

Examples such as, but not limited to:

• Were there any systemic factors that decreased the likelihood the client/patient/resident would receive appropriate and timely support?
• Were there any identified known issues during an AGMP (such as lack of proper PPE, AGMP’s occurring in a location without appropriate site ventilation system/HVAC) that may potentially contribute to large outbreaks of the virus to patients/clients/residents and employees?
• Were there any environmental factors if known that may have contributed to the spread of the virus that were contrary IP&C standards?
• Were there any systemic factors that decreased the likelihood of appropriate PPE usage or contributed to a lack of supplies?

If you answered YES to at least ONE of the above questions, the COVID-19 HAI is reportable and an occurrence report is to be completed and sent to the Patient Safety Coordinator(s) who will further review for potential designation as a critical incident.

Please print off and post the “A Guide to Determining if a COVID-19 HAI is a Critical Incident” 

Leads/Directors (or delegates) review and share the reporting requirements with all applicable staff.

Any questions should be directed to Jo-Anne Thompson & Tara Roberts

Submitted by:  Jo-Anne Thompson & Tara Roberts, Patient Safety Coordinators
For more information contact Jo-Anne: T 204-326-6411 ext. 2097 or email OR Tara:  T 204-428-2743 or email