MELANIE RODRIGUEZ,RN

Introduction
Being an accredited organization is not about
being a mistake/error free one.
It is about having a system to detect, report,
solve and uproot the causes of these errors as
well as acknowledge that we are all humans,
but we are not afraid to face and fix our
mistakes.



Barriers That Need To Be Overcome

lack of awareness of the need to report, what to report, and why;
lack of understanding of how to report;
staff feel they are too busy to make a report;
too much paperwork involved in reporting;
the patient recovers from the adverse event and the urgency
goes out of the situation;
fear of 'point-scoring' by colleagues, retribution by line
management, disciplinary action or litigation;
an assumption that someone else will make the report; no
evidence of timely feedback and/ or corrective action being taken
resulting from making a report
CBAHI Requirements
There are around 14 standards across the
CBAHI chapters that require presence of
reporting of occurrences, events, incidents, or
accidents.

FMS.5 Establishing a Safety committee consisting of the following
representatives -head of safety, head of security, head of
housekeeping, head of ER, head of Biomedical, head of
maintenance department, Representative from lab, infection
control, Nursing, TQM and
FMS.5.1 Meets at least 10 times/year on a monthly schedule, minutes
documented.
FMS.5.2 Discusses and analyzes all safety issues.
FMS.5.3 Reviews summary of the incidents/ OVR reports
and errors with high level of occurrence and suggests the
appropriate solution.
FMS.5.4 Reports Safety committee minutes to the hospital Director.
FMS.5.5 Communicates in writing with all Heads of Departments about the
risk issues in their areas.

LB.67 The lab develops the quality indicators
to evaluate and detect problems. These
following quality indicators are monitored:
LB.67.1. Incident reports.
LB.67.2. Turn around time for lab test.
LB.67.3 Specimen identification errors.
LB.67.4 Corrected Pathology and lab result
reports.

PH.37 There is a process for monitoring, detecting, and reporting adverse drug
reactions (ADRs) and includes:
PH.37.1 Written policy and procedure for ADR.
PH.37.2 Definition of a significant or serious ADR and timeframe for
reporting.
PH.37.3 ADR reporting forms are available
PH.37.4 Intensive analysis is performed for all significant or serious ADRs.
PH.37.5 Notification of treating physician.
PH.37.6 There is evidence that the patient receives appropriate care for
the ADR.
PH.37.7 There is evidence that the medical record has been flagged for
known allergies.
PH.37.8. Process for improving ADR reporting.
PH.37.9. Evidence of reporting any serious or unexpected ADR to the
MOH.

PH.38 There is a process for monitoring, identifying and
reporting significant medication errors & includes:
PH.38.1 Written policy and procedure for medication error
reporting.
PH.38.2 Definition of a significant medication error, timeframe
for reporting, and reporting format.
PH.38.3 Evidence of active reporting exists.
PH.38.4 Intensive root-cause analysis is performed for all
significant medication errors.
PH.38.5 Evidence for using reported data to improve
medication use process and reduce error rate.
PH.38.6 Mechanisms to prevent serious medication errors (e.g.
removal of concentrated intravenous potassium, magnesium,
hypertonic saline, other high risk stocks from nursing units).

IC.47 Infection control team monitors incidence
of exposure of the staff to pathogens in the
Hospital:
IC.47.1 There is a system for reporting, follow up &
management of exposure to open pulmonary TB.
IC.47.2 There is a system for reporting, follow up &
management of needle stick & sharp injuries.
IC.47.3 There is a system for reporting, follow up &
management of exposure vaccine-preventable viruses
(chickenpox, measles, mumps, and rubella).
IC.47.4 PPD conversion rates and sharp injuries rates are
calculated.

NR.11 The Nurse Leader develops a Quality Plan that is
consistent with the overall Hospital Quality Management
Plan and ensures essential monitoring is done and this
includes but is not limited to the following:
NR.11.1 Medication errors.
NR.11.2 Patient falls.
NR.11.3 Pressure ulcers.
NR.11.4 IV therapy (adherence to the policy).
NR.11.5 Hand washing (adherence to the policy).
NR.11.6 Nurses role in cardiopulmonary resuscitation (adherence
to the policy).
NR.11.7 Infection Control.
NR.22 There is a system for coordinating nursing
activities after duty hours to handle administrative and
clinical issues which includes but is not limited to:
NR.22.1 Patients who present with or demonstrate
medical/surgical emergencies or change of condition.
NR.22.2 Dying patients.
NR.22.3 Violent patients.
NR.22.4 All incident reports completed by nurses.
NR.22.5 Any adverse medication incidents.
NR.22.6 Any Sentinel events.

NR.36 Nursing follows the occurrence variance reporting
mechanism of the hospital that includes the following written
procedures:
NR.36.1 List of reportable occurrences (medication error, patient fall,
wrong procedure, etc.)
NR.36.2 identifies the person responsible for initiating the report.
NR.36.3 Identifies who is responsible for investigating the Occurrence.
NR.36.4 Describes how the occurrence is to be investigated (i.e.
algorithm).
NR.36.5 Outlines the expected corrective action plan and assigned
responsibility.
NR.36.6 Outlines the review process.
MS.11 The Medical Director works closely with
the Quality Management Director/leader and
Risk Manager in handling all near misses and
incidents and:
MS.11.1 Root cause analysis is performed when
appropriate.
MS.11.2 Emphasis is placed on improving
systems.
MS.11.3 The Actions taken are documented

MS.12 The Medical Director together with the
department heads and Quality Director, monitors
departments for the following:
MS.12.1 Patient assessments.
MS.12.2 Adverse events.
MS.12.3 Conscious sedation
MS.12.4 Quality of medical records.
MS.12.5 Medication errors.
MS.12.6 Sentinel events.
MS.12.7 High-risk services and procedures (e.g.
angiogram, ERCP, etc).
LD.40 The hospital has the essential administrative policies and procedures that
are reviewed and updated every (2) years, that includes but are not limited to:
LD. 40.1 Sentinel event.
LD. 40.2 Incident report or occurrence, variance report (OVR).
LD. 40.3 Medico-legal cases.
LD. 40.4 Child Abuse.
LD. 40.5 Patient rights.
LD. 40.6 Code of conduct for staff.
LD. 40.7 Informed consent.
LD. 40.8 Conscious sedation.
LD. 40.9 No code or dont resuscitate policy.
LD. 40.10 Dress code.
LD. 40.11 Admission, transfer and discharge.
LD. 40.12 Transfer to another facility.
LD. 40.13 Handling, use and administration of blood and blood products.
QM.25 There are outcome measurements
(indicators) based on the mission and scope of
services that may include but is not limited to:
QM.25.9 Adverse events (falls, injuries, pressure
ulcers).

QM.11 The hospital has an incident reporting system
(occurrence /variance /accident) Policy and form (OVA)
that staff follow and use when reporting adverse
events.
QM.11.1 Written policy on hospital incident reporting
system (OVR)
QM.11.2 Availability of hospital incident reporting form
QM.11.3 Evidence of Aggregated Incident reports

Functions of Quality
Department

setting and maintaining the standards and requirements
for reporting in conjunction with the CBAHI;
collecting, collating, categorizing and coding adverse
event information from all departments
assimilating other safety-related information from a
variety of existing reporting systems and other sources
analyzing information on adverse events and
maintenance of confidentiality of OVR

examining and tracking patterns and trends and acting
on their findings where risks are identified;
providing feedback to organizations and individuals,
including issue of 'patient safety alerts' to improve safety
and quality;
producing solutions to reduce risk and prevent harm to
future patients and specifying national goals and targets;
promoting a reporting culture within ShGH;
collaborating with relevant bodies.

Purpose
Occurrence Variance
Report is used to
help identify areas
needing
improvement or
recognition



.

Occurrence Variance
Reports (OVR) are
internal forms used to
document the details of
the incident and the
investigation of an
occurrence and the
corrective actions taken.





.
Injury to visitors or volunteers
while on the hospital premises

.
Any incident which is not
consistent to routine patient care
.

When to use
Occurrences not consistent with routine operation
of facility and /or adversely affects, threatens the
health or life of patient, visitor, employee, student
or volunteer.


.
Loss or damage to personal or hospital property.
.


Who should report
Everybody

/
.

What to report

Medication related issues
Narcotics issue
IV related
Transfusion
Laboratory related
OR related
Radiology related
Breaks in standard
precautions
.
.
.
.






Hospital acquired injury
Fall/Slip
Medical/Clinical Care
Patient
Identification/Labeling
errors
Medical Records
Documentation
Unauthorized Discharge
Fire & Safety
Security Variance

/
/ .






Wrong labeling of blood
samples
Suture needle broken
Delay in delivery of patient
meals.
Encoding of medicines
Smoking inside the hospital
premises
Patient/visitors tripping
Wrong Blood
Newborns identity
.
.

.
.
.
.
.
.


Actual cases

RESPONSIBILITIES

1. Supervisors and management personnel
2. :
- Consultation with involved employee(s).
- .
- Resolution of problems should take place when
possible within and between departments
-
.
Responsibilities
2. The employee who witnesses or
discovers
2 . :

- Immediate notification of Physician
on call and Section Supervisor
- .

3. Immediate Supervisor
3 . :
-Ensuring that all employees are aware of OVR
Reporting System; how to report and the
steps by steps procedure on how to complete
the form.
-
.
- Conduct immediate follow up after the
incident occurs.
- .
3. Immediate Supervisor
3 . :
- Document on the OVR the actions taken
and/or any corrective measures, taken to
prevent the recurrence of the event.
-
.
3. Immediate Supervisor
3 . :
- Forward the completed OVR report form to
the Quality Management office within 72 hours
(3 days) of the occurrence.
-

72 (
) .
3. Immediate Supervisor
3 . :
- Conduct any further investigation and
document, report investigated findings upon
request of the Hospital Administration the
Quality Management Committee or the Safety
Committee.

.
4. Physician
4 . :
- Documenting a brief statement of
his/her action(s) on the OVR form
immediately upon completing his
examination and/or the required
treatment or care.


.
5. The Quality and Patient Safety
Advocacy Department is responsible
for:
- Monitoring all OVR for follow up.
- Trending and preparing a monthly
summary
:
- .
- .
5. The Quality and Patient Safety Advocacy
Department is responsible for:
- Submitting a quarterly report to the
Quality Management Committee for
discussion and what action can be done
in the future to avoid recurrence.
- Upkeep the file
:
-

- / .
6. The Safety Dept
- Investigate all safety related incidents
- Organize a review team of selected
Safety Committee members to
investigate critical safety related
occurrences.
6 - :
- .
-
.
6. The Safety Officer
- Document the results of
investigation and corrective action
taken on the OVR form and
forwards it to the QPS dept.

6 - :
-

.

Policy
1. Report the details of any
occurrence, which has an
impacts in the care of patient.

1. /
.

2. OVR Form will be initiated
immediately after the incident.
And submit it to your immediate
supervisor within the current
work shift.
2.

.

3. The report will not be used
to criticize or blame the
actions of the staff
involved.
3.


4. Corrective actions shall be taken to
minimize risk of injury and adverse
outcomes. Corrective action(s) shall be
documented.
4.
.

/ / .

5. The Occurrence report shall
not be placed in the medical
record (Patient File) nor in
Employee File.
5.
( ) .

Confidentiality: 6.

6
6.1 OVR reports will be handled in outmost
confidentiality.
-
6.2 OVR should not be duplicated with exception of
the Quality department.
-
6.3 The information contained in the OVR form cannot
and will not be used against any individual as
basis for any disciplinary action.
-
.





6.4 Hospital staff are NOT allowed to discuss
the contents of an OVR or the events and
circumstances relative to the occurrence
either with patient, visitor or other members
of the staff, unless clarifying facts under
investigation with the proper authorities.
-


/ .
6.5 Discussion of general issues on OVR for
instructional or education purposes with
view to improving patient care is, however
strongly encouraged.

-

.

6.7 Names of involved/concerned
person should not be used. Use ID
number.

-
.


6.5 Discussion of general issues on OVR for
instructional or education purposes with view to
improving patient care is, however strongly
encouraged.

-

.

Occurrence Reporting :
Incident occurs


Awareness of the occurrence

Occurrence Variance Report Form is completed by the
person witnessed/affected by the occurrence
/
Supervisor evaluates occurrence if it meets the Sentinel
Event criteria

Meets
Sentinel
Event Criteria



Refer to Sentinel
Event Committee


Supervisor/designee
carries out required
investigation


No
Yes
Physician informed completes the
follow up as needed

Other
services/d
ept.
involved

Take corrective action as needed and
document on the OVR form (Part I)



No
Yes
Refer to QIC/Supervisor of involved dept. and
forward carbon copy to TQM


Involved dept. supervisor/designee
investigate & document follow up
action/recommendation on OVR form (Part
I)


( )
Inform initiating dept.
of the action taken



Forward to
QPS Dept.




QPS follows
up as
needed




TQM trends
all OVRs

QPS forwards
quarterly reports
to concerned
areas, QMC &
Safety Committee



Sentinel Event
An unexpected occurrence
involving death, serious
physical or psychological
injury to the patient



.
Reportable Cases
An unanticipated
death
Major permanent
loss of limb or
function, not
related to the
patients illness or
underlying
condition
Infant abduction
.



.




suicidal attempt within
the hospital premises.
Rape
Physical assault of a
patient, staff or visitor
Infant discharge to the
wrong family


.



.
.

Reportable Cases
Significant hemolytic
transfusion reaction
involving administration
of blood or blood
products having major
blood group
incompatibilities

Surgery on the wrong
patient or body part

Significant Medication
errors (Overdose causing
death to patient.)





.

(
).

Reportable Cases
Sentinel Event Reporting Process

1. Immediate notification 1 . :
Departmental Quality Improvement
Designee/Coordinator (QIC/Designee)
/ .

2. The QIC/D will notify 2 . /

:
Head of the Department - .

3. The QID/C will call or bleep Quality Improvement
Coordinator phone or in person.
/
.
4. Occurrence Report should be submitted to the
Quality Improvement Coordinator
4 . .

5. Sentinel Event Coordinator will conduct an
investigation and interview the involved person and/or
any witness of the event.



6. SE Coordinator will notify the Sentinel Event
Committee and convene for a meeting.
6 .
.

7. Root Cause Analysis will be initiated and facilitated.
7 . .

8. Action plan will be designed as appropriate and implemented
immediately.
8 . .

9. All investigation and conclusion documentation will be in the
custody of the Quality Management Department and
remained confidential.
9 .

.

10. Follow up assessment will be conducted by SEC and the concerned
department within six (6) months of the event
10 .
.

Remember. ......
Avoid personal
opinions
OVR is for
reporting purposes
only
It is not placed in
the patients
medical record nor
to the employees
file



.


.


.
The more you
report the
least errors be
committed,
and more
improvements
could be done.






.
Remember. ......
See no incident, Hear no incident , Speak no
incident
, , .
If you dont report,
and things be
discovered, then
you may expect
that you will be
reported.




-


.

Your report counts because
YOU COUNT!
- .