EVENT REPORT
An event is any happening, which is not consistent with the routine operation of the hospital or the routine care of a particular patient.It may be an accident or a situation that might result in an accident.Examples of Events by type are:1.
Medication Event1.Wrong drug/dose dispensed2.Wrong drug/dose administered3.Wrong drug labeling/preparation4.Wrong patient ID on Rx/order5.Wrong route/site6.Omission/ delayed dose7.Deteriorated/ expired drug 8.Prescribing error9.Transcribing/inputing error10. Compliance11. Adverse reaction(*note that we still require doctor to fill ADR because contents are different and ADR is also govt required form)12. Others
2.
Safetyn Firen Violent patient/visitor/staffn Falln Employee injuryn Patient injuryn Lost or damaged propertyn General security eventn Others
3.
Needle Stick / Exposuren Needle-stick injuryn Exposure to body fluidn Others
4 Surgical/Invasive Proceduren Contrast Reactionn Instrument Countn Pre-op assessmentn Unplanned return to ORn Wrong body partn Post-op complicationsn Anesthesia complicationsn Fetal injuryn Patient Wound Infectionn Others
5. Diagnosis Relatedn Delay in Diagnosisn Wrong Diagnosisn Improper test preformedn Specimen lostn Test ordered but not preformedn Inaccurate test resultsn Poor result from treatmentn Unhappy result from treatmentn Others
6.Patient Rightsn No consent signedn Improper use of restraintsn Confidentialityn Sexual misconduct (verbal or physical)n Waiting time/ Delay/ Availability n Others
7.Equipment/Instrument n Availabilityn Defectiven Improper use n Damaged or brokenn Others
8.Financial n Direct billing/ insurancen Pre-certificationn Payment too expensiven Payment related to referraln Chargesn Incomplete billsn Copy feen Price not toldn Others
9Communicationn Nursen Physiciann Receptionistsn Other Admin staffn Cashiern Pharmacyn Radiology n Others
Communicationn Nursen Physiciann Receptionistsn Other Admin staffn Cashiern Pharmacyn Radiology n Others
Environment/Facilities n Air Contaminationn Construction noisen Elevatorn Others
Othersn Failure to follow proceduren Improper documentationn Patient identification n Phone/ operatorl Unregistered Med. processn IT issuesn Medical record issuesn Physician not available or delayedn Others
Near Miss
A near miss is any process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome such as an unexpected, undesirable or potentially dangerous occurrence in the organization. When encountering a near miss, the occurrence reporting should be followed as per this policy.
Near Misses include: any process that potentially could have caused a sentinel event. Examples include but are not limited to: potential falls where the patient or staff did not fall but could have, wrong medications dispensed but not taken by the patient. It is the responsibility of the Risk Management Officer to review events and classify them as near misses. Near misses will be shared at the Quality Improvement Committee for further follow up and action.
Sentinel Event
A sentinel or serious event is defined as an undesirable and unexpected occurrence involving death, serious physical or psychological injury or the risk thereof, or has the potential to adversely affect the reputation of the hospital. Serious injury specifically includes loss of limb or function. The phrase, “or the risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.
All sentinel / serious events must immediately be verbally reported to the department manager or supervisor/hospital charge nurse, and thereafter the Event Form completed.The department manager or supervisor/hospital charge nurse shall then proceed as per the Sentinel Event policy
Level I- Incident: Incidents where the potential for litigation is thought to be non-existent. No injury or outcome that alters a patient/visitor/staff's function. This includes minor complaints that do not affect the safety of the patient/staff or visitor and can be easily resolved. Minor issues including billing complaints.
Level II- Non-Serious Incident: Incidents where the potential for litigation is thought to be minimal. Minor injury or impairment in which a patient/visitor/staff's function may be altered temporarily. Complaints are not potentially risk management issues but need to be investigated and resolved. This may include minor complaints, lost property, minor treatment problems with no obvious side effects to the patient. Equipment failure with no direct implications on patient care.
Level III- Mild Incident: Involves upset patient/visitor/staff that although no harm was done, have written a formal letter or complained to the hospital management. Incidents that have the potential to increase risk to the hospital and the safety of the hospital. Falls that did not result in any injury, documentation errors, patient identification errors that may or may not have resulted in potential patient harm.
Level IV- Serious: Incidents where the potential for litigation is thought to be prevalent. Major injury or impairment in which the patient/visitor/staff's function is altered long term or permanently. This would include any medication events or needle sticks. This also include cases sent for peer review, missed diagnosis, falls that resulted in injury, burns, equipment failure that had implications on patient care or safety, and breach of confidentiality. Potential near misses.
Level V- Tragic: Incidents where the potential is that litigation could be initiated at any time. Worst negative patient/visitor/staff outcomes such as permanent disability, or death. This includes any sentinel event.
If there is a possibility that the event Form could be construed as a criticism of a staff member’s performance, that staff member shall be informed of the Form and be given an opportunity to respond.
Some events require a peer review to be performed.The list of events requiring automatic peer review is detailed on the Peer Review Trigger List.The RMO and CMO can also request a peer review on an ad-hoc basis.Peer review shall be carried out in accordance with the Peer Review Policy.
Medication Events
When a medication events occurs, a copy of the event shall be forwarded to the Pharmacy Manager.The Pharmacy Manager shall report medication errors to the Pharmacy & Therapeutics committee and in the monthly pharmacy department meeting. Improvements in medication processes and staff training are used to prevent errors in the future.
请问小马哥，您的这些资料可以在哪找到。 jdl 发表于 2013-2-25 14:12 static/image/common/back.gif
请问小马哥，您的这些资料可以在哪找到。
JCI认证网站，WHO患者安全专题 谢谢
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