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

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Presentation Transcript

What is an Occurrence Report?

  • An occurrence report is a document used to record an event when it occurs

  • Occurrences are reported each time an occurrence occurs

Who Should Report?

  • Anyone who discovers, witnesses or is notified of an occurrence should complete an occurrence report

  • All staff, all shifts, all locations must report

What Do I Report?

  • 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

Why Do I Report?

  • To promote patient safety

  • To improve delivery of patient care

  • To minimize injury and loss

What is Blameless Reporting?

  • 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 Happens When I Report an Event?

  • 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?

  • 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?

  • Data analysis and trend identification, loss control methods are identified to improve practice

  • Identified issues are reported to Administration

What are the Elements of a Good Report?

  • Person affected - patient, staff, 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?

  • Analysis of Occurrence outcome box checked appropriately (if applicable)

  • Contributing Factors to event (if applicable)

  • Staff Productivity at the time of event (if applicable)

What are the Elements of a Good Report?

  • Occurrence report forwarded to Quality Management within 48 hours

  • All serious events, contact Quality Management immediately

Why Do We Report Occurrences?

  • 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

What are the Common Occurrence Themes?

  • Falls

  • Employee Injury - Back & Knee

  • Treatment Procedure Issues

    • Hand offs

    • Lab (labels, nurse draws, orders missed)

    • General sign off orders

What are the Common Occurrence Themes?

  • 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 About Confidentiality?

  • 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

You are an Important Part of the Solution!

  • Document what you assess, do and evaluate in patient care

  • Communicate effectively

  • Report accurately

  • Use your chain of command


For Questions Contact:

  • Laurie Oakes, Director, Quality & Clinical Safety

  • Yolanda Edwards, Data Systems Coordinator