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Occurrence Variance Report and Sentinel Event Reporting System
1. Occurrence Variance Report (OVR)
and
Sentinel Event Reporting System
Dr.Hisham Aldabbagh
MSc.Internal Medicine
Kingdom of SaudiArabia
Ministry of Health
Gurayat HealthAffairs
Gurayat GeneralHospital
السعودية العربية المملكة
الصحة وزارة
القريات بمحافظة الصحية الشؤون
العام القريات مستشفى
2. Purpose
Occurrence Variance Report (OVR)is used
to help identify areas needing improvement
or recognition.
Occurrence Variance Report (OVR) are
internal forms used to document the details
of the incident and the investigation of an
occurrence and the corrective actions
taken.
Email:ovr-qurt@moh.gov.sa
3. When to use?
Injury to visitors
or volunteers while on the hospital premises
Any incident which is not consistent to
routine patient care
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.
Email:ovr-qurt@moh.gov.sa
4. Who should reports?
Everybody
All medical, nursing, technician, and non
medical staff or employees should participate
in OVR reporting
Email:ovr-qurt@moh.gov.sa
5. What to report?
Miscommunication
Accidental needle prick
Absconded
Blood extraction
Problem in cleanliness
Medicines not transcribed
No response to call
Email:ovr-qurt@moh.gov.sa
6. What to report?
Violation in standard precaution
Delays in:_______:
Non-availability of supplies/forms
Expired blood, or medications
Wrong patient identification
Other (specify:)
Email:ovr-qurt@moh.gov.sa
7. OVR Policy
1- Report the details of any occurrence,
which has an impacts in the care of
patient.
2- OVR Form will be initiated immediately
after the incident. And submit it to your
immediate supervisor within the current
work shift.
3- The report will not be used to criticize or
blame the actions of the staff involved
Email:ovr-qurt@moh.gov.sa
8. 4- Corrective Actions
Should be taken to minimize risk of
injury and adverse outcomes.
Corrective action(s) should be
documented.
5- The Occurrence report should not
be placed in the medical record
(Patient File) nor in Employee File.
Email:ovr-qurt@moh.gov.sa
9. 6- Confidentiality
6.1. OVR reports
Will be handled in outmost confidentiality.
6.2. OVR should not be duplicated with
exception of the QPS 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.
Email:ovr-qurt@moh.gov.sa
10. 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.
Email:ovr-qurt@moh.gov.sa
11. 6.5. Discussion of
general issues on OVR
for instructional or
education purposes with view to improving
patient care is, however strongly encouraged.
6.6. Names of
involved/ concerned
person
should not be used.
Email:ovr-qurt@moh.gov.sa
12. Responsibilities
1. Immediate Supervisors
Consultation with the involved employee(s).
Resolution of problems should take place
when possible within and between
departments
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.
Email:ovr-qurt@moh.gov.sa
13. Conduct immediate action and follow
up after the incident occurs.
Document on the OVR the actions
taken and/or any corrective
measures, taken to prevent the
recurrence of the event.
Email:ovr-qurt@moh.gov.sa
14. Evaluates incident if
meets sentinel event criteria
Forward the completed (original) OVR
report form to the Quality and Patient Safety
office within 72 hours (3 days) of the
occurrence
Conduct any further investigation and
document, report investigated findings upon
request of the Hospital Administration the
Quality and Patient Safety Committee or the
Safety Committee
Email:ovr-qurt@moh.gov.sa
15. 2. The employee who witnesses or
discovers
2.1 Immediate notification of attending
physician in case of injury and Immediate
Supervisor
Email:ovr-qurt@moh.gov.sa
16. 3. Attending Physician
Complete and document his/her action(s) on
the OVR form immediately upon carrying
out his examination
and/or the required
treatment or care
Email:ovr-qurt@moh.gov.sa
17. 4- Quality and
Patient
Safety Department
Is responsible for:
Monitoring all OVR for follow up.
Trending and preparing a monthly
summary.
Submitting a quarterly report to the
Quality and Patient Safety Committee for
discussion and what action can be done in
the future to avoid recurrence.
Upkeep the file
Email:ovr-qurt@moh.gov.sa
18. 5. The Risk
Management
Investigate all safety related incidents
Organize a review team of selected Safety
Committee members to investigate
critical safety related occurrences
Document the results of investigation and
corrective action taken on the OVR form
and forwards it to the QPS
Email:ovr-qurt@moh.gov.sa
19. Equipment and Forms
1- Occurrence Variance Report
Form
2- Email: ovr-qurt@moh.gov.sa
Email: ovr-qurt@moh.gov.sa
20. Email: ovr-qurt@moh.gov.sa
GURAYAT GEN.HOSPITAL
THIS FORM SHOULD BE FORWARDED THROUGH YOUR IMMEDIATE SUPERVISOR TO THE TQM OFFICE WITHIN 72 HOURS
EmployeeReportingtheIncident
PART A: OCCURRENCE DETAILS :) (
Event Details: Type of Occurrence: Person (s) affected: / _ /
Date of Occurrence: _____________:
Time: ____________________________ :
Location:___________________________
Date of Report:: _________________:
Time: _____________________________ :
Reported By: :
Medicine Surgery
OB/Gyne Pedia
ICU NICU
L & D ED
Laboratory Radiology
Medical Records
Anesthesia Pharmacy
Other:
__________________________________
Profession: Pharmacist
Nurse Physician
Technician Other _________
Miscommunication
Accidental needle prick
Absconded
Blood extraction
Problem in cleanliness
Medicines not transcribed
No response to call
Violation in standard precaution
Delays in:____________________________:
Non-availability of supplies/forms
Expired blood
Wrong patient identification
Safety _____________________________
Other (specify): ) (
________________________________________
________________________________________
Inpatient
Outpatient
Visitor
Employee
Other (specify): ) (
______________________________________
If Employee :
Department Name: :
______________________________________
Position: :
_______________________________________
ID Number: :
_______________________________________
Brief Description of the event :
___________________________________________________________________________________________________________________________________
Supervisor
PART B: IMMEDIATE SUPERVISOR NOTIFICATION :) (
Name of Supervisor : ___________________________ Signature : _________________ Date/time notified : __________________
Sentinel event criteria? YES NO OVR Forwarded to : _______________________________________
(Involved/concerned Dept.)
Physician
(ifneeded)
PART C: PHYSICIAN FOLLOW-UP (In case injury occurred) :) (
Needs physician intervention : Yes No Seen by physician?: Yes No
Assessment/diagnosis____________________________________________________________________________________________________: /
Examination/Treatment Done: First aid Blood works Seen by employee clinic
/ Wound dressing CT/ X-ray Returned to work Medications Sutures
Seen by ED Observations Sick leave Hospitalized
Injury outcome : No injury Minor Serious Death Other (specify) ) ( :_____________________
Physician name :________________________________________ Signature :____________________ Date/time : _________________
dDepartment
PART D: ACTION TAKEN(To be completed by involved/concerned department for follow-up)
) ( ) (
Corrective action taken: :
_________________________________________________________________________________________________________________________________
___Recommendations to prevent recurrence: :
Name : ____________________________ Position : ________________ Signature : _____________ Date/time : _________________
PART E: (To be filled by TQM) ( :)
STATUS OF ACTION TAKEN: :
Appropriate & complete Inappropriate & incomplete No further action required
Referred to ___________________________________________________ Other ____________________________________
Name : __________________________________________ Signature : ___________________________________ Date & time : ______________________
NOT TO BE USED AS LEGAL DOCUMENTATION. FOR Q.I PURPOSE ONLY .
Original Copy to be forwarded to involved/concerned dept. after completion forward to TQM; Duplicate copy to TQM Revised
March 2013
OCCURRENCE VARIANCE REPORT (OVR) FORM
CONFIDENTIAL
NOT PART OF MEDICAL RECORD/ EMPLOYEE FILE
FILE NO.
NAME: ______________________________________________
:
AGE: SEX: M F :
NATIONALITY:
________________________________________:
CONSULTANT IN-CHARGE:______________________:
23. Reportable Cases
An unanticipated death
Major permanent loss of limb or
function, not related to the patient’s
illness or underlying condition
Infant abduction
25. Reportable Cases
Significant hemolytic blood 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.)
26. Sentinel Event
Reporting Process
1- Immediate notification;
Quality and Patient Safety department,
Risk Management
2- Occurrence Variance Report should be
submitted to the Quality and Patient Safety
department/ Risk Management
27. 3- The QPS/RM will notify
Head of the department
Medical director
Hospital director
4- The QPS/RM will form Sentinel
Event Committee (SEC) regarding that
event, and convene for a meeting, by
phone or in person.
28. 5- Sentinel Event Committee will
conduct an investigation and
interview the involved person
and/or any witness of the event.
6- Root Cause Analysis will be
initiated and facilitated by Sentinel
Event Committee.
29. 7- Action plan will be designed as appropriate
and implemented immediately.
8- All correlated information and procedures
of the sentinel event should be recorded at the
official sentinel event website of MOH, as
they are required, with initial recording that
should start within 24 hour after the
occurrence of the sentinel event.
30. 9- All investigation and conclusion
documentation will be in the custody of the
Quality and Patient Safety Department
and remained confidential.
10- Follow up assessment will be
conducted by SEC and the concerned
department within six (6) months of the
event.
