Quality and Patient Safety

Physician Hotline

The Performance Improvement Department maintains a reporting mechanism for Medical Staff members that is designed to collect information related to Medical Staff and patient care issues. The confidential phone number is 670-6677.

Patient Safety

Tiffany Parker, Patient Safety Officer, 670-3315
Physician Hotline, 670-6677
Gaye Hay, RN, Director, Performance Improvement and Accreditation, 670-3748

Event Reporting

Adverse events are entered into the Event Management System in the Patient Safety office. This is where such things as patient falls and medication errors, as well as physician issues, are tracked.

Event Reporting Policy (1.1004)

Last Reviewed: March 18, 2016 | Next Review: March 18, 2019

An event report ("First Report") will be completed on any Sentinel Event, Adverse Event or Medication Event, which involves patients, visitors, volunteers, students, employees, or medical and ancillary staff members. It is the responsibility of individuals who are employed by or affiliated with Hendrick Medical Center and its affiliates ("Hendrick") to report events. It is recognized that patients may have undesired outcomes even when receiving routine, expected and appropriate care. Such outcomes are not within the reporting requirements of this Policy.

To identify those events where actions may or could be taken to improve outcomes, modify policies and/or procedures; or provide education that will foster improved safety for patients, visitors, volunteers, students, employees, medical and ancillary staff members; and to facilitate timely identification and resolution of risks in an effort to reduce or prevent the potential for injury or loss.


Informed Consent

Physicians are responsible for providing information and obtaining consent. Consent forms are available through the EMR.

Contact: Carol Kramer, 325-670-2487, or Tiffany Parker, 325-670-3315

Informed Consent, 2.1005

Last Reviewed: July 29, 2016 | Next Review: July 29, 2019

Hendrick Medical Center and its affiliates ("Hendrick") recognizes that it is the responsibility of the physician to obtain informed consent of a patient or the person having legal authority to give consent for the patient (surrogate decision-maker) and to document that consent prior to treatment according to policies of Hendrick and the laws of the State of Texas.



Restraint Use, 3.1083

Last Reviewed: February 5, 2016 | Next Review: February 6, 2019


Hendrick Medical Center will establish minimum standards for the care of patients requiring restraint use at Hendrick Medical Center.





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