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A part from an incident, accident or a sentinel event, OVR would implement events, that should be of a mandatory sstep, for accreditation of health institutions.
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Prepared By Dr Gamal Soliman
Health Care Quality Management
Occurrence Variance Reports
And Quality Methods
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Agenda : June-2010
Parts
1- Occurrence Variance Reports-June/28
2- Sentinel and High risk Events
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Part1
OCCURRENCE VARIANCE REPORT SYSTEM
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Purpose
To provide a systematic, standardized hospital-wide mechanism to identify and/or
to develop prevention /improvement programs
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
DEFINITIONS
An Occurrence: any occurrence that is not consistent with the routine operation which happens at the premises, Housing
external Activities, and transportation
Occurrence Variance Report (OVR): an internal form _____________ used to document the details of the occurrence/event and the investigation of an occurrence and the corrective actions taken.
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Adverse Drug/Instrument Event: in which the use of medication (drug or biologic) at any dose, a medical device, improper administration of medications
On-the-job Occurrence: an occurrence that takes place in the Hospital or outside the premises when the employee is carrying out
his/her duties
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Adverse Event: are unexpected incidents, therapeutic misadventures, iatrogenic injuries or other adverse occurrences
directly associated with care or services provided.
Some examples of adverse events include: patient falls, medication errors, procedural errors/complications,
Sentinel Event: A “Sentinel Event” is an unexpected occurrence involving death or serious physical or psychological injury, or the risk
thereof, not related to the natural course of a patient’s illness HomicideSurgery on the wrong patient Child Abduction or discharge to the wrong familyHemolytic Blood Transfusion
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Near Miss: Is an event or situation that could have resulted in an accident, Injury or illness,
Malpractice: Improper or unethical conduct or unreasonable lack of skill by a holder of a
professional or official position, often applied to physicians, dentists, nursing to denote negligent
or unskillful performance
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Variation: the differences in results obtained in measuring the same event more than once.
Grouped into common causes and special causes. Too much variation often leads to waste and loss -- Giving rise to undesirable patient health outcomes and
increased cost of health services.
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
RESPONSIBILITY
1- It is the responsibility of the person in charge to assure the stability of any injury in the first priority and have the OVR completed. to assure the stability of any injury in the first priority and have the OVR completed.
2- The Employee who witness or discover an occurrence has the professional responsibility for:
Immediately notifying:
The physician on call if the occurrence involves any question of patient or employee injury or harm.
And The area supervisor. To initiate the OVR
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
3- The Supervisor is responsible for:
Ensuring that all employees are aware of OVR system as well as Conducting immediate follow-up of the occurrence and Ensuring thorough and accurate completion of the OVR form and Forwarding the completed OVR form within 72 hours and finally Conducting any further investigation
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
4- The Physician: she/he is responsible to document a brief statement of his/her
action(s) on the OVR form immediately upon completion the patient / employee
examination
5-QM Department is responsible for : Monitoring all OVR(s) for follow –up, Trending
and preparing a monthly summary of all reported occurrences, Submitting a quarterly report to the TQM and Maintaining a file of all OVR submitted to the TQM office for 3 years
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6-The Safety Officer
( need to be employed)
is responsible for:
Investigating all safety related occurrences, Activating a Review Team, Documenting the results of investigation and corrective action , Returning the completed form to the TQM office, Reviewing monthly summary data
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
POLICYIt is the responsibility of all employees to
immediately report the details of any occurrence and This report is to be used to identify the facts
surrounding the occurrence and will not be used to criticize or speculate on actions of the staff
involved
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
POLICY
The OVR form shall not be photocopied or placed in the medical record. The terms “incident” and “error” shall not be used in the
medical
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
POLICY
It is the responsibility of patient Safety manager to supply the Safety Committee with a quarterly summary
Confidentiality All OVR shall be handled and maintained in a confidential manner,
OVR shall not be duplicated, with exception of the TQM department
The information contained in the OVR form cannot and shall not be used against any individual as the sole basis for disciplinary action.
Hospital staff is not at liberty to discuss the contents of an OVR or the events and circumstances relative to the occurrence either with patient, visitor or other members
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
PROCEDURE
General instructions: (guidelines how to use the Form)
Use of OVR template.
If not possible use blue ink. Avoid pencils, in clear legible handwriting
Write objective view and comments. Avoid personal opinions.
The OVR form consists of the following sections
Upper right corner: Patient Information
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality ManagementOccurrence Details:
(by the person witnessed / affected by the occurrence)
Person(s) affected
Affected employee information
Occurrence brief description
Immediate action taken
Witness(es) Information
Supervisor Notification (included – decision of sentinel event)
Physician Follow Up Notification
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Severity of Injury:
Slight / minor treatment: the incident resulted in abrasion, reddening of the
skin, a bruise or other apparently minor damage to tissue. The
treatment required was non-invasive for e.g. topical ointment, dressing or ice packs. Medication incidents that
may require monitoring such as changes in vital signs or lab tests.
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Moderate injury: the incident resulted in hemorrhage, tissue impairment and
required clinical intervention. For e.g. suturing, first and second degree burns. Medication incidents with potential for
serious outcomes that require intervention and monitoring.
Serious injury: the incident resulted in fracture, hemorrhage, aspiration, third
degree burns, serious drug reaction or the incident resulted in admission to hospital (if outpatient), transfer to critical care area, or
increase in length of stay (inpatient).
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality ManagementDeath
Integrated Occurrence Strategy (as needed) Follow up, by responsible person/department, to include:
recommendationsTQM office commentsType of occurrences Contributing factors
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Part 2
Sentinel and High risk Events
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
PURPOSE
1. identify Sentinel Events
2. make appropriate individuals aware of S.E.
3. investigate and understand the causes
4. make changes in the hospital systems to reduce the probability of S.E.
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
DefinitionsAction Plan: is the product of the Root cause Analysis that identifies the strategies to reduce the probability of S.E. in the future.
CBAHI : Central Board of Accreditation for Healthcare Institutions
Policy : The “Policy” is this Sentinel and Root Cause Analysis policy
Root Cause Analysis : a process for identifying the causal factor(s) that underlie variation in performance including the occurrence or possible occurrence of a S.E.
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Sentinel Event: is an unexpected occurrence involving death or serious physical or psychological injury not related to the natural course of a patient’s illness including delays in diagnosis and treatment
Example Types,
SuicideHomicideSurgery on the wrong patient or body partImpairment (major/permanent loss of bodily functionAny unexpected death that is not the result of the patient’s underlying medical condition Rape Child Abductiongg
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Task Force : is the subcommittee appointed by the Committee to:
(1)investigate an occurrence or process variation
(2) (2) determine whether such occurrence or process variation meets the definition of a Sentinel Event,
(3) complete a thorough and credible Root Cause Analysis and resulting Action Plan describing the hospital’s risk reduction strategies
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
Responsibility
1- Creation of Committee – S.E. Committee
2- Composition of Committee
Administrator
Medical Director
Director of Nursing
Assistant Administrator for Clinical Services
Ex-officio members
Chief Legal Officer
Healthcare Risk Manager
Risk manager
Designated staff persons6/28/2010
Health Care Quality Management
Duties of the Committee Investigate an occurrence or process variationDetermine whether such occurrence or process variation meets the definition of a Sentinel EventEnsure completion of a thorough and credible Root Cause Analysis and resulting Action Plan
6/28/2010 Prepared By Dr Gamal Soliman
Prepared By Dr Gamal Soliman
Health Care Quality Management
PROCEDURE
Application of Policy Identification of Sentinel event
6/28/2010
Appointment of Task Force
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
Prepared By Dr Gamal Soliman
Health Care Quality Management
6/28/2010
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