Mandatory incident reporting

What qualifies as a procedural incident?

• Any final agency action against the ambulance service by any federal or state entity related to substandard patient care, health care fraud, or the ambulance service’s Drug Enforcement Agency (DEA) license.
• Any civil judgment or criminal conviction in a case brought by federal, state, or local authorities involving the operation, management, or ownership of an ambulance service; and contains allegations related to substandard patient care, health care fraud, or moral turpitude. A guilty verdict, a plea of guilty, or a plea of nolo contendere (no contest) accepted by the court is considered a conviction.
• Any instance in which an EMS provider is terminated or suspended by the ambulance service based on the good cause rules set forth in 6 CCR 1015-3, Chapter One.
• Any suspension or revocation of a medical director’s license to practice by the Colorado Medical Board.
• The unexpected or untimely separation of a medical director from an ambulance service whether voluntary or involuntary. All other separations or transitions must be reported by the medical director pursuant to 6 CCR 1015-3, Chapter Two.

Other incidents

• Any incident during response or while providing patient care in which an employee, contractor, or volunteer of the ambulance service knowingly:
  • Commits physical assault against another person pursuant to Article 3 of Title 18, C.R.S.; or
  • Commits sexual assault, pursuant to Article 3 of Title 18, C.R.S. As used here, “sexual assault” includes:
    • Any improper sexual contact, touching, intrusion, or penetration that an ambulance service employee, contractor, or volunteer inflicts upon another person; or
    • Any instance in which an EMS provider, while purporting to offer a medical service, engages in treatment or examination of a patient for other than a bona fide medical purpose or in a manner substantially inconsistent with reasonable medical practices.
• Any incident involving the commission of patient abuse, including the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish; or patient neglect, including the failure to provide goods and services necessary to attain and maintain physical and mental well-being by the ambulance service or its employees, contractors, or volunteers.
• Any unauthorized appropriation or possession of medications, supplies, equipment, money, or personal items.
• The response to an incident, or treatment of a patient, by an ambulance service’s employees, contractors, or volunteers while impaired by the use of alcohol or drugs.
• Any instance of care provided by someone impersonating a licensed healthcare provider, including someone practicing without a valid certification, license, or privilege to practice.
• The death or injury of an occupant of an ambulance that is licensed and permitted by the Department and is a direct result of a motor vehicle collision occurring during response or transport by the ambulance service.
• Administration of an adulterated or contaminated drug, device, or biologic provided by the ambulance service.
• The following incidents that lead to injury, illness, or death to a patient not ordinarily expected as a result of the patient’s condition:
  • A medication error or medical act error
  • An invasive procedure performed on the wrong site
  • The use or function of a device in which the device is used in a manner other than as intended or approved by medical direction
  • The use of physical restraints or chemical restraints
  • Patient suicide or attempted suicide that occurs during the provision of patient care

A one-time extension may be requested for these types of incidents.

How to report incidents

Starting July 1, 2024, all mandatory incidents must be reported via the steps below. To request a one-time extension to the 90 calendar day report deadline for the "other incidents" listed above, email cdphe_groundambulance@state.co.us before filling out the form below. 

Form availability

The mandatory incident report form will be available in OATH on July 1, 2024. It will not appear in OATH before that date. The mandatory incident report form can only be started and submitted by the following OATH positions at the ambulance service.

• Profile gatekeeper
• Ground ambulance administrator
• Medical director

Steps to submit an incident

1. Log in to your OATH account.
2. Click 'Applications' on the left menu.
3. Click 'View Services Applications' next to the name of the service for which you are submitting a mandatory incident report.
4. Click the 'Apply Now' button next to the "Ground Ambulance License - Mandatory Incident Report" form.
5. Complete the 1-page application form and submit it for review. Documentation is required to be uploaded to the form.

• Mandatory incident reporting FAQ