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Occurrence Variance Reports
And Quality Methods

6/28/2010

Prepared By Dr Gamal Soliman
Agenda : June-2010

Parts
1- Occurrence Variance Reports-June/28
2- Sentinel and High risk Events

6/28/2010

Prepared By ...
Part1
OCCURRENCE VARIANCE REPORT SYSTEM

6/28/2010

Prepared By Dr Gamal Soliman
Purpose
To provide a systematic, standardized
hospital-wide mechanism to identify and/or
to develop prevention /improvemen...
DEFINITIONS
An Occurrence: any occurrence that is not
consistent with the routine operation which
happens at the
premises,...
Adverse Drug/Instrument Event: in
which the use of medication (drug or
biologic) at any dose, a medical
device, improper a...
Adverse Event: are unexpected incidents, therapeutic
misadventures, iatrogenic injuries or other adverse occurrences
direc...
Near Miss: Is an event or situation that could
have resulted in an accident, Injury or illness,
Malpractice: Improper or u...
Variation: the differences in results
obtained in measuring the same event
more than once.
Grouped into common causes and ...
RESPONSIBILITY

1- It is the responsibility of the person in charge to assure
the stability of any injury in the first pri...
3- The Supervisor is responsible for:
Ensuring that all employees are aware of
OVR system as well as Conducting
immediate ...
4- The Physician: she/he is responsible to
document a brief statement of his/her
action(s) on the OVR form immediately upo...
6-The Safety Officer
( need to be employed)
is responsible for:
Investigating all safety related
occurrences, Activating a...
POLICY
It is the responsibility of all employees to
immediately report the details of any occurrence
and This report is to...
POLICY
The OVR form shall not be
photocopied or placed in the medical
record. The terms “incident” and
“error” shall not b...
POLICY
It is the responsibility of patient Safety manager to
supply the Safety Committee with a quarterly
summary
Confiden...
PROCEDURE
General instructions: (guidelines how to use
the Form)
Use of OVR template.
If not possible use blue ink. Avoid ...
Occurrence Details:
(by the person witnessed / affected by
the occurrence)
Person(s) affected
Affected employee informatio...
Severity of Injury:
Slight / minor treatment: the incident
resulted in abrasion, reddening of the
skin, a bruise or other ...
Moderate injury: the incident resulted in
hemorrhage, tissue impairment and
required clinical intervention. For e.g.
sutur...
Death
Integrated Occurrence Strategy (as
needed) Follow up, by responsible
person/department, to include:
recommendations
...
Part 2

Sentinel and High risk Events

6/28/2010

Prepared By Dr Gamal Soliman
PURPOSE
1.

identify Sentinel Events

2.

make appropriate individuals aware of S.E.

3.

investigate and understand the c...
Definitions
Action Plan: is the product of the Root cause
Analysis that identifies the strategies to reduce
the probabilit...
Sentinel Event: is an unexpected occurrence involving
death or serious physical or psychological injury not
related to the...
Task Force : is the subcommittee
appointed by the Committee to:
(1)investigate an occurrence or
process variation
(2) (2) ...
Responsibility
1- Creation of Committee – S.E. Committee
2- Composition of Committee
Administrator
Medical Director
Direct...
Duties of the Committee
Investigate an occurrence or process
variation
Determine whether such occurrence or
process variat...
PROCEDURE
Application of Policy
Identification of Sentinel event
Appointment of Task Force

6/28/2010

Prepared By Dr Gama...
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
6/28/2010

Prepared By Dr Gamal Soliman
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Quality Health Occurence-Variance Report-Part 1.ppt

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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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Quality Health Occurence-Variance Report-Part 1.ppt

  1. 1. Occurrence Variance Reports And Quality Methods 6/28/2010 Prepared By Dr Gamal Soliman
  2. 2. Agenda : June-2010 Parts 1- Occurrence Variance Reports-June/28 2- Sentinel and High risk Events 6/28/2010 Prepared By Dr Gamal Soliman
  3. 3. Part1 OCCURRENCE VARIANCE REPORT SYSTEM 6/28/2010 Prepared By Dr Gamal Soliman
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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 Homicide Surgery on the wrong patient Child Abduction or discharge to the wrong family Hemolytic Blood Transfusion 6/28/2010 Prepared By Dr Gamal Soliman
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. POLICY It 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. Occurrence 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
  19. 19. 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
  20. 20. 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
  21. 21. Death Integrated Occurrence Strategy (as needed) Follow up, by responsible person/department, to include: recommendations TQM office comments Type of occurrences Contributing factors  6/28/2010 Prepared By Dr Gamal Soliman
  22. 22. Part 2 Sentinel and High risk Events 6/28/2010 Prepared By Dr Gamal Soliman
  23. 23. 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
  24. 24. Definitions Action 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
  25. 25. 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, Suicide Homicide Surgery on the wrong patient or body part Impairment (major/permanent loss of bodily function Any unexpected death that is not the result of the patient’s underlying medical condition  Rape  Child Abduction gg 6/28/2010 Prepared By Dr Gamal Soliman
  26. 26. 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
  27. 27. 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 persons 6/28/2010 Prepared By Dr Gamal Soliman
  28. 28. Duties of the Committee Investigate an occurrence or process variation Determine whether such occurrence or process variation meets the definition of a Sentinel Event Ensure completion of a thorough and credible Root Cause Analysis and resulting Action Plan 6/28/2010 Prepared By Dr Gamal Soliman
  29. 29. PROCEDURE Application of Policy Identification of Sentinel event Appointment of Task Force 6/28/2010 Prepared By Dr Gamal Soliman
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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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