Dr. Mushtaq A. Khosa

29 January 2015

OCCURRENCE VARIANCE REPORT ()

To provide a systematic, standardized hospital-wide mechanism to identify and/or to develop prevention/improvement programs which have direct or indirect adverse effect on patient care; and which represent a potential hazard to patients, visitors, volunteers, trainees, employees or the facility as quality improvement approach. OVR shall be used as a mechanism for monitoring, Quality Improvement in a Non Punitive Approach.

PURPOSE

To establish clear systems for hospital-wide reporting of information related to medical/health care errors, and to provide a confidential mechanism of identification, tracking, trending, and follow-up

of all incidences that pose an actual or potential safety risk to patients, families, visitors and staff. Variances include events ranging from “falls "to near misses or sentinel events with serious adverse outcomes, occurring in the hospital setting.

Purpose

an internal form _____________ used to document the details of the occurrence/event and the investigation of an occurrence and the corrective actions taken.

Occurrence Variance Report

({{ {[[[[[[[{[[[[[{OVR}

An event which is not consistent with routine patient care or the routine operation of the facility and which adversely affects or threatens the health or life of the patient, visitor ,employee, student or volunteer which involves loss or damage to personal and/or hospital property.

An Occurrence is defined as any event or circumstance that deviates from established

standards or care.

OCCURRENCE

It is essential that following any occurrence variance or adverse event, an OVR is completed and forwarded to Quality Management Department (QMD). The report is checked for completeness, logged, forwarded to the designated QM Coordinator, sent to the Concerned Department where appropriate action is taken relating to the event. On completion the OVR is returned to Quality Management Department where the designated coordinator will check the action and provide feedback as required. It is then scanned, returned to the Reporter, and any concerned persons/department heads. In some instances an OVR may involve two departments and a photocopy of the original OVR is made and sent to the respective department for follow up.

Process

If a particular OVR requires further investigation, this is the responsibility of the concerned Department. For example a policy may need to be revised or developed, a procedure reviewed, equipment changed, resources re-allocated.

If, on receiving an OVR it is classified as a Sentinel Event it is raised to the Director of QMD who will initiate appropriate action and/or decide on an investigation using, for example, a Root Cause Analysis approach.

Process

It is an unwanted, undesirable and usually unanticipated event such as death of a patient, an employee or a visitor in a healthcare institute.

Adverse event

It is the difference in results obtained in measuring the same phenomenon more than once

variance

An event or situation that could have resulted as an accident, injury or illness but did not either by chance or through timely intervention .

Near Miss

A Sentinel Event is defined as an unexpected occurrence involving the death or serious

physical or psychological injury, or risk thereof, including loss of limb or function, signaling

the need for immediate investigation and response.

Sentinel Event

Unexplained or unexpected deaths or permanent loss or function of a limb that is not a result of the patients medical condition.

Sentinel events

1. Surgery on the wrong patient2. Surgery on wrong body part3. Wrong surgical procedure.4. Infant abduction5. Child discharge to the wrong family6. Hemolytic blood transfusion7. Patient suicide in the Hospital8. Rape/sexual harassment of a patient, staff or visitor

Examples of sentinel events

9. Retained Instrument or sponge10. Intra vascular Gas embolism11. Maternal Death12. Medication error s leading to death or Major morbidity.13. Patient’s fall resulting in death or loss of function of a body part.

Examples of Sentinel events

All sentinel events require immediate attention, investigation and appropriate response by the corresponding committees.

ALL EVENTS SHOULD GENERATE AN OVR.

Sentinel event policy.

1. Identification of a sentinel event.2. Appointment of a Task Force3. Completion of root cause analysis4. Committee Report.5. All reports generated by committee or Task force members are confidential and Privileged.

Procedure.

It is the Responsibity 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.

Responsibility

NURSES

TECHNICIANSDOCTORSHEAD OF THE DEPARTMENTS

QMD

HOUSE KEEPINGSOCIAL WORKERS

Reporter

The employee who witnesses an occurrence has the professional responsibility to immediately notify:

a) The Physician on call if the occurrence involves any question of patient and/or employee injury or harm.

b)The Area supervisor to Generate an OVR.

Responsibility

Ensure that all the employees are aware of the OVR system.

Conduct immediate follow of the occurrence.Ensure thorough and accurate completion of the OVR form.

Forward the completed OVR within 72 hrs to QMD to initiate further process.

Role of the Supervisor

Investigate all safety related incidents.

Organize a review team of selected safety committee to investigate critical safety related occurrences.

Document the result of investigations and corrective measures taken on the OVR form and forward it to the TQM department.

The safety officer

QMD is responsible for managing all OVR’s for follow up ,Trending and preparing a monthly summary of all

Reported occurrences. The QMD will officially submit the report to the head of the concerned department for further course of action and make sure that all the process shall remain confidential submitting a quarterly report to the regional TQM maintaining a record file of all OVR’s submitted. Identify steps ,hold discussions on what actions can be taken to avoid recurrence of an event.

Quality Management department.

1434-1436 OVR PIE CHART (COMPARISON)

34.83%

32.52%

32.58%

1434-1436 OVR

1436 (MONTH 1-8)

1435

1434

1434 OVR pie chart

1434 OVR

Patient Misbehavior 8

Absconded 5

Needle Prick 4

Medical Record 3

Medication Error 3

Oxygen Flowmeter broken 3

Laboratory Services 2

Patient Identification 1

Laundry Services 1

Overstaying Patient 1

25%

15.62%

12.5%9.37%

9.37%

9.37%

6.25%

3.12%3.12% 3.12%

1434 OVR

Patient Misbehavior

Absconded

Needle Prick

Medical Record

Medication Error

Oxygen Flowmeter broken

Laboratory Services

Patient Identification

Laundry Services

Overstaying Patient

1435 OVR pie chart

24.13%

13.79%

13.79%10.34%

10.34%

6.89%

3.44%

3.44%

3.44%3.44%

3.44%3.44%

1435 OVR

Absconded

Security Problem

Misbehavior of staff

Needle Prick

Resident refuse to see pt. in DR

Patient Identification

No staff in reception

Suspected MERS-COV notendorsed

Laboratory Services

Maintenance for Equipment

Bladder Injury

Refusal to Accept patient

1435 OVR

Absconded 7 Security Problem 4 Misbehavior of staff 4 Needle Prick 3 Resident refuse to see pt. in DR 3 Patient Identification 2 No staff in reception 1 Suspected MERS-COV not endorsed 1 Laboratory Services 1 Maintenance for Equipment 1 Bladder Injury 1 Refusal to Accept patient 1

1436 OVR pie chart(Month 1-8)

27.58%

24.13%

13.79%

13.79%

6.89%

3.44%

3.44%3.44%3.44%

1436 OVRMonth 1-8

Needle Prick

Violent Patient

Laboratory Services

Absconded

Misbehavior of employee

Medication error

Refused to answer phone duringon-call

Patient Identification

Referring patients without doctor

1436 OVR (Month 1-8)

Needle Prick 8 Violent Patient 7 Laboratory Services 4 Absconded 4 Misbehavior of employee 2 Medication error 1 Refused to answer phone during on-call 1 Patient Identification 1 Referring patients without doctor 1

OVR form

OVR form

OVR form

• Miscommunication• Accidental needle prick• Absconding staff/patient• Undocumented /wrong blood extraction• Problems in cleanliness• Prescribed medicines not transcribed• No response to call involving consultants ,staff, security and

others .• Violations in standard precautions • Delays • Non availability of supplies /forms• Expired blood or Medications • Wrong patient Identification.• Others (specify)

REPORT THE DETAILS OF ANY OCCURANCE WHICH HAS AN ADVERSE IMPACT ON PATIENT CARE.

What to report.

The Occurrence report shall not be placed in the medical record (Patient File) nor in Employee OVR should not be duplicated with exception of the TQM department.

The information contained in the OVR form cannot and will not be used against any individual as basis for any disciplinary action File.

What not to do

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

What not to do

The aim of the study was to improve Occurrence Variance Reporting SystemOccurrence variance reporting (OVR) is very essential for ensuring patient and staff safety, quality of care and risk management.Steps to identify, report, and follow up an adverse event include identifying an adverse event, report the adverse event, explore the cause of the event through root cause analysis, and use the result of the analysis to make improvement

Summary

THANK YOU