Occurrence Reports

1. Occurrence Reports

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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)

12. What are the Elements of a Good Report? • Occurrence report forwarded to Quality Management within 48 hours • All serious events, contact Quality Management immediately

13. 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

14. 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

15. 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)

16. 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

17. 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 • IF YOU ARE NOT SURE, ASK!

18. For Questions Contact: • Laurie Oakes, Director, Quality & Clinical Safety • Yolanda Edwards, Data Systems Coordinator