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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