NASA Procedural Requirements

NPR 1850.1 Effective Date: May 11, 2010 Expiration Date: December 31, 2024

Subject: Quality Assurance of the NASA Medical Care (Revalidated w/change 1)

Responsible Office: Office of the Chief Health & Medical Officer

Appendix D. Medical Incident Investigation

D.1 Introduction

D.1.1 Medical incident investigations will be conducted by an independent panel according to the procedures noted below. The panel will include personnel with similar experience and expertise as those involved in the medical incident. Physician members will be board certified and experienced in the appropriate area of interest.

D.2 Responsibilities

D.2.1 The Center Chief Medical Officer/Medical Director (CMO/MD) will ensure that the Chief Health and Medical Officer (CHMO) is notified of all medical incidents involving serious physical or psychological injury or death.

D.2.2 The Center Chief Medical Officer/Medical Director and Center Occupational Health Contracting Officer Technical Representative (COTR), or the appropriate official that serves as that COTR, will appoint the independent panel to investigate the incident.

D.2.3 The CHMO will appoint the investigating panel in cases involving the CMO/MD.

D.3 Process Description

D.3.1 Minimum factors the independent panel will consider include:

a. Human Factors such as:

• Proper training, certifications, and privileges;
• Competency;
• Fatigue (work-rest cycles);
• Judgment;
• Stressors (external and work related);
• Interpersonal relationships with coworkers; and
• Possible drug or alcohol influence.

b. Operational and System Factors such as:

• Communication issues;
• Biomedical equipment or technical failures;
• Staffing and scheduling issues;
• Proper procedure guidelines documented and implemented; and
• Proper supervision of clinical activities.

c. Witnesses - All witnesses will be informed that their statements may not be confidential and that they will be interviewed upon their consent.

d. Possible Criminal Behavior - If a criminal violation is suspected, the CHMO must be immediately notified in writing who, in turn, will notify appropriate NASA legal counsel (i.e., the Office of General Counsel and the Office of Inspector General). The investigation will stop pending further guidance from the CHMO and the appropriate NASA legal counsel.

D.3.2 The panel will determine if the standard of care was met.

D.3.3 The panel will report findings and provide all relevant records and data collected to the CHMO. The CHMO may convene the Center CMOs and/or elements of the Medical Policy Board to review the investigation results and recommend actions. Adverse actions taken against privileged providers will be performed in accordance with Appendix E.

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