EVENT REPORT

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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 Event 1.  Wrong drug/dose dispensed 2.  Wrong drug/dose administered 3.  Wrong drug labeling/preparation 4.  Wrong patient ID on Rx/order 5.  Wrong route/site 6.  Omission/ delayed dose 7.  Deteriorated/ expired drug 8.  Prescribing error 9.  Transcribing/inputing error 10. Compliance 11. 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.

Safety n   Fire n   Violent patient/visitor/staff n   Fall n   Employee injury n   Patient injury n   Lost or damaged property n   General security event n   Others

3.

Needle Stick / Exposure n   Needle-stick injury n    Exposure to body fluid n   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         9 Communicationn   Nursen   Physiciann   Receptionistsn   Other Admin staffn   Cashiern   Pharmacyn   Radiology n   Others Communication n   Nurse n   Physician n   Receptionists n   Other Admin staff n   Cashier n   Pharmacy n   Radiology n   Others Environment/Facilities n   Air Contamination n   Construction noise n   Elevator n   Others Others n   Failure to follow procedure n   Improper documentation n   Patient identification n   Phone/ operator l   Unregistered Med. process n   IT issues n   Medical record issues n   Physician not available or delayed n   Others

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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

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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.

jdl

请问小马哥，您的这些资料可以在哪找到。

男丁格尔

jdl 发表于 2013-2-25 14:12

                               
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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

jdl

谢谢