1. Occurrence Reports

2. An occurrence report is a document used to record an event when it occurs Occurrences are reported each time an occurrence occurs What is an Occurrence Report?

3. Anyone who discovers, witnesses or is notified of an occurrence should complete an occurrence report All staff, all shifts, all locations must report Who Should Report?

4. Actual and potential risks to patient care Deviations from established standards or guidelines (whether there is an injury or not) Near miss incidents Departmental complaints - please report to your manager What Do I Report?

5. To promote patient safety To improve delivery of patient care To minimize injury and loss Why Do I Report?

6. The purpose of reporting is to be proactive and improve systems to minimize harm All efforts are taken to encourage active reporting of incidents Blameless reporting - to report information to benefit patient safety without fear of reprisal for reporting What is Blameless Reporting?

7. Event entered into the Risk Master system Risk Manager & Quality Mgt Staff investigate serious events (interview staff, chart review, etc.) All occurrences are tracked to see if there are any identifiable trends What Happens When I Report an Event?

8. Decision made to see if a root cause analysis is needed Identification of medical devices involved (if applicable) All reported occurrences are read and reviewed What Happens When I Report an Event?

9. Data analysis and trend identification, loss control methods are identified to improve practice Identified issues are reported to Administration What Happens When I Report an Event?

10. Person affected – patient or visitor Date, time and location of occurrence Date and time report completed Factual description of event Manager’s comment about event Condition of patient (if applicable) What are the Elements of a Good Report?

11. Event Severity Indicated Contributing Factors to event (if applicable) Occurrence report forwarded to Quality Management within 48 hours All serious events resulting in major injury or outcome, permanent disability, coma or death contact Quality Management immediately What are the Elements of a Good Report?

12. To assure the organization understands where unsafe situations are occurring. The collective data from reports is used to: Trend safety Study and modify processes, systems, equipment or the environment to ensure safety for all Why Do We Report Occurrences?

13. Falls Treatment Procedure Issues Hand offs Lab (labels, nurse draws, orders missed) General sign off orders What are the Common Occurrence Themes?

14. Med errors Missed or extra dose Wrong drug or dose Proper monitoring not checked (peak/trough; INR; glucose) Rate of IV; pumps wrong, not programmed correctly; no verifications on opiates and insulin (high risk drugs) What are the Common Occurrence Themes?

15. All occurrences are confidential and to be treated consistent with patient information No occurrence report is to be used as a disciplinary instrument against an employee reporting any unsafe or inappropriate situation What About Confidentiality?

16. Document what you assess, do and evaluate in patient care Communicate effectively Report accurately Use your chain of command IF YOU ARE NOT SURE, ASK! You are an Important Part of the Solution!

17. Marge McFadden, Director Quality Management Jovonne Foster, Manager Data Support Services For Questions Contact: