Sentinel Events & OVR (lecture)
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Sentinel Events & OVR (lecture)

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A brief lecture ppt for the students and professionals of Healthcare Quality Management & Patient Safety. This lecture presented in Arar Central Hospital of KSA for CME of doctors & nurses. Sentinel ...

A brief lecture ppt for the students and professionals of Healthcare Quality Management & Patient Safety. This lecture presented in Arar Central Hospital of KSA for CME of doctors & nurses. Sentinel Events topic is a basic topic of Healthcare Quality Management and they can be controlled by caring of International Patient Safety Goals.

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    Sentinel Events & OVR (lecture) Sentinel Events & OVR (lecture) Presentation Transcript

    • OVR&OVR&SENTINELSENTINELEVENTSEVENTSTQMDepartment LectureByDr. Aqeel Ahmed KhanQMCoordinator-ACH
    • 2CONTENTS:CONTENTS:Definitions of termsDefinitions of terms• OCCOURANCEOCCOURANCE• OVROVR• ADVERSE EVENTADVERSE EVENT• VARIENCEVARIENCE• NEAR MISS (& why it should beNEAR MISS (& why it should bereported)reported)• SENTINEL EVENTSSENTINEL EVENTS• “ ““ “ (Types)(Types)• “ ““ “ (policy)(policy)
    • 3CONTENTS:CONTENTS:• SENTINEL EVENTS (Procedure)SENTINEL EVENTS (Procedure)• How to deal with sentinel/adverseHow to deal with sentinel/adverseeventevent• Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR• Who should report /responsibilitiesWho should report /responsibilities(Employee, attending physician, immediate(Employee, attending physician, immediatesupervisor, TQM department, safety officer)supervisor, TQM department, safety officer)• OVR policyOVR policy• OVR form restrictionsOVR form restrictions• OVR form sampleOVR form sample
    • 4OCCURRENCEOCCURRENCE• An event which is not consistent with routineAn event which is not consistent with routinepatient care or with the routine operation ofpatient care or with the routine operation ofthe facility & which adversely affects orthe facility & which adversely affects orthreatens the health or life of patient, visitor,threatens the health or life of patient, visitor,employee, student or volunteer whichemployee, student or volunteer whichinvolves loss or damage to personal orinvolves loss or damage to personal orhospital property. An occurrence alsohospital property. An occurrence alsoincludes any event that might other wiseincludes any event that might other wiseresult in any other adverse situation or aresult in any other adverse situation or aclaim against the organization.claim against the organization.
    • 5OCCURRENCEOCCURRENCEVARIANCE REPORTVARIANCE REPORT(OVR) DEFINITION:(OVR) DEFINITION:• An internal form which is issued toAn internal form which is issued todocument the details of thedocument the details of theoccurrence / event and theoccurrence / event and theinvestigation of an occurrence andinvestigation of an occurrence andthe corrective actions taken.the corrective actions taken.
    • 6ADVERSE EVENTADVERSE EVENT• It is an unwanted, undesirable andIt is an unwanted, undesirable andusually unanticipated event such asusually unanticipated event such asdeath of patient, an employee, or adeath of patient, an employee, or avisitor in a health care organization.visitor in a health care organization.Occurrences such as patient falls areOccurrences such as patient falls arealso considered adverse events ifalso considered adverse events ifthere is no permanent effect on thethere is no permanent effect on thepatient.patient.
    • 7VARIANCEVARIANCE• Is the difference in results obtainedIs the difference in results obtainedin measuring the samein measuring the samephenomenon more than once.phenomenon more than once.Excessive variation frequently leadsExcessive variation frequently leadsto waste and loss; such as theto waste and loss; such as theoccurrence of undesirable patientoccurrence of undesirable patienthealth outcomes and increased costhealth outcomes and increased costof health services.of health services.
    • 8• An event or situation that could haveAn event or situation that could haveresulted in an accident, injury orresulted in an accident, injury orillness but did not either by chance orillness but did not either by chance orthrough timely intervention.through timely intervention.NEAR MISSNEAR MISS
    • 9Why should reportWhy should reportNEAR MISSNEAR MISSSentinel eventsAdverse eventsNear misses, other accidentsand occurrences• They haveThey havethe samethe sameroot causes,root causes,as sentinelas sentinelevents, soevents, sothey shouldthey shouldalso bealso bereportedreported
    • 10SENTINEL EVENTSENTINEL EVENT(DEFINITION)(DEFINITION)• Any unexpected occurrenceAny unexpected occurrenceinvolving death, serious physical orinvolving death, serious physical orpsychological injury or the riskpsychological injury or the riskthereof, and any event that mightthereof, and any event that mightcause embarrassment or risk to thecause embarrassment or risk to thehospital with potential legalhospital with potential legalimplications and / or media inquiresimplications and / or media inquiresor coverage.or coverage.
    • 11SENTINEL EVENTSENTINEL EVENT• The phrase “or the risk thereof”The phrase “or the risk thereof”includes any process variation forincludes any process variation forwhich a recurrence would carry awhich a recurrence would carry asignificant chance of a serioussignificant chance of a seriousadverse outcome. Such events areadverse outcome. Such events arecalled “sentinel” because theycalled “sentinel” because theysignal the need for immediatesignal the need for immediateinvestigation and response.investigation and response.
    • 12SENTINEL EVENTSENTINEL EVENT(TYPES)(TYPES)• Serious injury includes but is notSerious injury includes but is notlimited to:limited to:– Unexplained or unexpected deathsUnexplained or unexpected deathsor permanent loss of limb or functionor permanent loss of limb or functionthat is not a result of the patient’sthat is not a result of the patient’smedical condition.medical condition.
    • 13– Surgery on theSurgery on thewrong patientwrong patient– Surgery on wrongSurgery on wrongbody partsbody parts– Wrong procedureWrong procedureSurgerySurgerySENTINEL EVENTSENTINEL EVENT(TYPES)(TYPES)
    • 14SENTINEL EVENTSENTINEL EVENT– Rape of a patient, staff or visitorRape of a patient, staff or visitor– Infant abductionInfant abduction– Unexpected death of full-term infantUnexpected death of full-term infant– Child discharge to the wrong familyChild discharge to the wrong family– Hemolytic blood transfusionHemolytic blood transfusion– Patient suicide in the hospitalPatient suicide in the hospital
    • 15– Retained instrument or spongeRetained instrument or sponge– Intravascular gas embolismIntravascular gas embolism– Maternal deathMaternal death– Medication Errors leading to death orMedication Errors leading to death ormajor morbiditymajor morbidity– Patient’s fall resulting death orPatient’s fall resulting death orsevere dysfunction of body partsevere dysfunction of body partSENTINEL EVENTSENTINEL EVENT
    • 16SENTINEL EVENTSENTINEL EVENTPOLICYPOLICY–All sentinel events requireAll sentinel events requireimmediate investigation andimmediate investigation andappropriate response by theappropriate response by thecorresponding committees. Allcorresponding committees. Allevents should have an occurrenceevents should have an occurrencegenerated report (OVR)generated report (OVR)
    • 17SENTINEL EVENTSENTINEL EVENTPROCEDUREPROCEDURE1.1. Identification of a Sentinel EventIdentification of a Sentinel Event2.2. Appointment of Task ForceAppointment of Task Force3.3. Completion of Root Cause AnalysisCompletion of Root Cause Analysis4.4. Committee ReportCommittee Report5.5. Any report or documents generatedAny report or documents generatedby the Task Force are Confidentialby the Task Force are Confidentialand Privilegedand Privileged
    • 18SENTINELEVENTImmediateContainmentActionReporting andNotificationInvestigationand ReviewAction Plan& MonitoringHow to deal with a SentinelHow to deal with a SentinelEvent/Adverse EventEvent/Adverse EventUnit heads /dept chairsAP, Unitheads / deptchairs +CustomerServiceUnit heads / deptchairs, AP, Team +Risk ManagementOfficeUnit heads /dept chairs,SQD + MQIOPersonsaccountable
    • 19PURPOSE OF OVRPURPOSE OF OVR• To provide a systematic hospital –To provide a systematic hospital –wide identification mechanism aswide identification mechanism asquality improvement tool for earlyquality improvement tool for earlydetection and prevention ofdetection and prevention ofproblems which have (or may have)problems which have (or may have)an adverse patient outcome andan adverse patient outcome andrepresent a potential hazard torepresent a potential hazard topatients, visitors, volunteers,patients, visitors, volunteers,students or employees.students or employees.
    • 20PURPOSE OF OVRPURPOSE OF OVR• To plan and implement correctiveTo plan and implement correctivemeasures through identification bymeasures through identification byroot cause analysis.root cause analysis.• To analyze the data and developTo analyze the data and developpreventive measures periodically.preventive measures periodically.• To help identify areas needingTo help identify areas needingimprovement or recognitionimprovement or recognition
    • 21WHEN TO USE OVR:WHEN TO USE OVR:• Injury to visitors or volunteersInjury to visitors or volunteerswhile on the hospital premiseswhile on the hospital premises• Any incident which is notAny incident which is notconsistent to routine patientconsistent to routine patientcarecare
    • 22WHEN TO USE OVR:WHEN TO USE OVR:• Occurrences not consistent withOccurrences not consistent withroutine operation of facility and /orroutine operation of facility and /oradversely affects, threatens theadversely affects, threatens thehealth or life of patient, visitor,health or life of patient, visitor,employee, student or volunteer.employee, student or volunteer.• Loss or damage to personal orLoss or damage to personal orhospital property.hospital property.
    • 23WHO SHOULDWHO SHOULDREPORT?REPORT?•EverybodyEverybody
    • 24RESPONSIBILITIES:RESPONSIBILITIES:• The employee who witnesses orThe employee who witnesses ordiscoversdiscovers–Immediate notification ofImmediate notification ofattending physician in case ofattending physician in case ofinjury and Immediate Supervisorinjury and Immediate Supervisor
    • 25RESPONSIBILITIES:RESPONSIBILITIES:• Attending PhysicianAttending Physician–Complete and document his/herComplete and document his/heraction (s) on the OVR formaction (s) on the OVR formimmediately upon carrying out hisimmediately upon carrying out hisexamination and/or the requiredexamination and/or the requiredtreatment or care.treatment or care.
    • 26RESPONSIBILITIES:RESPONSIBILITIES:• Immediate SupervisorsImmediate Supervisors–Consultation with the involvedConsultation with the involvedemployee (s)employee (s)–Resolution of problems shouldResolution of problems shouldtake place when possible withintake place when possible withinand between departmentsand between departments
    • 27RESPONSIBILITIES:RESPONSIBILITIES:• Immediate SupervisorsImmediate Supervisors–Ensuring that all employees areEnsuring that all employees areaware of OVR Reporting System;aware of OVR Reporting System;how to report and the steps byhow to report and the steps bysteps procedure on how tosteps procedure on how tocomplete the form.complete the form.–Conduct immediate action andConduct immediate action andfollow up after the incident occursfollow up after the incident occurs
    • 28RESPONSIBILITIES:RESPONSIBILITIES:• Immediate SupervisorsImmediate Supervisors–Document on the OVR the actionsDocument on the OVR the actionstaken and/or any correctivetaken and/or any correctivemeasures, taken to prevent themeasures, taken to prevent therecurrence of the eventrecurrence of the event–Evaluates incident if meetsEvaluates incident if meetssentinel event criteriasentinel event criteria
    • 29RESPONSIBILITIES:RESPONSIBILITIES:• Immediate SupervisorsImmediate Supervisors– Forward the completed (original) OVRForward the completed (original) OVRreport form to the Total Qualityreport form to the Total QualityManagement office within 72 hours (3Management office within 72 hours (3days) of the occurrencedays) of the occurrence– Conduct any further investigation andConduct any further investigation anddocument, report investigateddocument, report investigatedfindings upon request of the Hospitalfindings upon request of the HospitalAdministration the QualityAdministration the QualityManagement CommitteeManagement Committee
    • 30RESPONSIBILITIES:RESPONSIBILITIES:•The Total QualityThe Total QualityManagement DepartmentManagement Department–Monitoring all OVR for followMonitoring all OVR for followupup–Trending and preparing aTrending and preparing amonthly summarymonthly summary
    • 31RESPONSIBILITIES:RESPONSIBILITIES:•The Total QualityThe Total QualityManagement DepartmentManagement Department–Submitting a quarterly reportSubmitting a quarterly reportto the Quality Managementto the Quality ManagementCommittee for discussion andCommittee for discussion andwhat action can be done in thewhat action can be done in thefuture to avoid recurrence.future to avoid recurrence.–Upkeep the fileUpkeep the file
    • 32RESPONSIBILITIES:RESPONSIBILITIES:• The Safety OfficerThe Safety Officer– Investigate all safety related incidentsInvestigate all safety related incidents– Organize a review team of selectedOrganize a review team of selectedSafety Committee members toSafety Committee members toinvestigate critical safety relatedinvestigate critical safety relatedoccurrencesoccurrences– Document the results of investigationDocument the results of investigationand corrective action taken on theand corrective action taken on theOVR form and forwards it to the TQM.OVR form and forwards it to the TQM.
    • 33OVR POLICYOVR POLICY• Report the details of any occurrence,Report the details of any occurrence,which has an impacts in the care ofwhich has an impacts in the care ofpatient.patient.• OVR Form will be initiated immediatelyOVR Form will be initiated immediatelyafter the incident. And submit it to yourafter the incident. And submit it to yourimmediate supervisor within the currentimmediate supervisor within the currentwork shift.work shift.• All sections of the OVR form must beAll sections of the OVR form must becompleted and submitted to thecompleted and submitted to theimmediate supervisor within the currentimmediate supervisor within the currentwork shift.work shift.
    • 34OVR POLICYOVR POLICY• The report will not be used toThe report will not be used tocriticize or blame the actions of thecriticize or blame the actions of thestaff involved.staff involved.• Corrective actions shall be taken toCorrective actions shall be taken tominimize risk of injury and adverseminimize risk of injury and adverseoutcomes. Corrective action (s) shalloutcomes. Corrective action (s) shallbe documented.be documented.• The Occurrence report shall not beThe Occurrence report shall not beplaced in the medical record (Patientplaced in the medical record (PatientFile) nor in Employee File.File) nor in Employee File.
    • 35OVR POLICYOVR POLICY• Confidentiality:Confidentiality:All OVR shall be handled andAll OVR shall be handled andmaintained in a confidentialmaintained in a confidentialmanner with access to suchmanner with access to suchdocumentation restricted todocumentation restricted toauthorized individuals.authorized individuals.OVR shall not be duplicated, withOVR shall not be duplicated, withexception of the QM department,exception of the QM department,when deemed necessary.when deemed necessary.
    • 36OVR POLICYOVR POLICYThe information contained in theThe information contained in theOVR form cannot and shall not beOVR form cannot and shall not beused against any individual as theused against any individual as thesole basis for disciplinary action.sole basis for disciplinary action.The involved person’s MRN #The involved person’s MRN #instead of his/her name will beinstead of his/her name will beused on the OVR form.used on the OVR form.
    • 37OVR POLICYOVR POLICY Hospital staff is not at liberty to discussHospital staff is not at liberty to discussthe content of an OVR or the eventsthe content of an OVR or the eventsand circumstances relative to theand circumstances relative to theoccurrence either with patient, visitoroccurrence either with patient, visitoror other members of the staff, unlessor other members of the staff, unlessclarifying facts under investigationclarifying facts under investigationwith the proper authorities.with the proper authorities. Discussion of general issues on OVR forDiscussion of general issues on OVR forinstructional or educational purposesinstructional or educational purposeswith view to improving patient care iswith view to improving patient care ishowever strongly encouraged.however strongly encouraged.
    • 38The OVR form shouldThe OVR form shouldnot:not:Be PhotocopiedBe PhotocopiedBe Placed in Medical RecordBe Placed in Medical RecordBe DiscussedBe DiscussedBe given Personal OpinionsBe given Personal Opinions
    • 39Do Not:Do Not:Use the names ofUse the names ofinvolved/concerned person.involved/concerned person.Use the content of the OVRUse the content of the OVRagainst any individual foragainst any individual fordisciplinary action.disciplinary action.Divulge any informationDivulge any informationwritten on the OVR form towritten on the OVR form tounconcerned individuals &unconcerned individuals &media.media.
    • 40EQUIPMENTS /EQUIPMENTS /FORMS:FORMS:OccurrenceOccurrenceVarianceVarianceReport FormReport Form
    • 41OVR FORMOVR FORMDATE & TIME OF INCIDENT: _______________________WARD/ROOM/DEPARTMENT: ______________________DIAGNOSIS: _____________________________________STATUS (CHECK ONE): ( ) IN-PATIENT ( ) OUT-PATIENT( ) VISITOR( ) EMPLOYEE ( ) OTHER (SPECIFY): _____________________MEDICAL RECORD NUMBER: _____________AGE: _____________SEX: __________________NATIONALITY: __________________________DATE & TIME RECORD INITIATED:____________________________________________________________________________________INTRAVENOUS RELATED( ) Central Line( ) Contrast Media Reaction( ) Extravasate( ) Occluded( ) Precipitate( ) Site Red/Swollen( ) Tubing Leak( ) Expired Fluid( ) Additive Related( ) Transfusion Reaction( ) Other __________________PROCEDURE VARIANCE( ) Delay( ) Missing Files/Notes( ) Performed on Wrong Site( ) Consent( ) Patient Identification( ) Wrong Patient( ) Wrong Procedure( ) Lost/Spoiled Specimen( ) No Response( ) Wrong File( ) Procedure Cancellation( ) Notes in Wrong File( ) Inadequate/Inappropriate entry( ) No Label/Addressograph( ) Other___________________________BEHAVIOR( ) DAMA( ) Absconded( ) Dissatisfied with Care( ) Patient Behaivior( ) Family/Visitor Behaivior( ) Staff Behaivior( ) Borrowed Medical Record Card( ) Non-ComplianceHAZARD/SAFETY( ) Burn( ) Chemical Spill( ) Electrical Shock( ) Fire( ) Gas( ) Hazardous Waste( ) Radiation Exposure( ) Chemical Splash( ) Water Spill( )Other________________________SECURITY VARIANCE( ) Damage/Loss of Property( ) Drug Count Variance( ) Drug Keys( ) Prescription Alteration( ) Security Problem( ) Suicide Attempt( ) Other ___________________EQUIPMENT/SUPPLIES( ) Electrical Problem( ) Equipment Not Working( ) Mechanical Problem( ) Operator Not Qualified( ) Wrong Equipment( ) Missing Equipment( ) Not Available( ) Out of Stock( ) Other ___________________ARAR CENTRAL HOSPITALPART A – ADDRESSOGRAPHOCCURRENCE VARIANCE REPORT(NOT PART OF THE MEDICAL RECORD)OCCURRENCE TYPE
    • 42PART B 2-1 – DESCRIBE THE OCCURRENCE (STATE THE FACTS)FACTUAL DESCRIPTION…………………………………………………………………………………………………………………………………………….…..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………..………………Reported By: Name: ………….………………………..…..…. ID No. ………….… Dept. …………... Position………….……..Witness By: Name: ………………………………………….. ID No. ……….…… Dept. …….……... Position………………...IMMEDIATE ACTION: (PART B 2-2)Physician Notified: ( ) YES ( ) NO ( ) NOT APPLICABLEDid MD see patient: ( ) YES ( ) NOIf yes, investigation/s done: ( ) X-ray ( ) Suture ( ) Blood work ( ) MedicationAssessment/Diagnosis: (PART B 3-1)………………………………………………………………………………………………………………………….………………..…………………………………………………………………………………………………………………………………………….……..………SEVERITY CODE (CHECK ONE) PART B 3-2( ) Minor - no injury or minor treatment (i.e. abrasion; no increased length of stay; no increased level of care)( ) Moderate - increased length of stay; increased level of care( ) Major - temporary or permanent lessening of body functions( ) Sentinel - catastrophic; death or major permanent loss of function( ) Near Miss - potentially severe outcomeIMMEDIATE ACTION (PART C)Action taken by initiating department Action taken by the responding department……………………………………………………………..……………………………………………………………………………..………………………………………………………………………..…………………………………………………………………..………………………………………………………………………..………………………………………………………………………..……………………………………………………………………..……………………………………………………………………………………………………………………………………….………………………………………………………………….…………………………………………………………………….…………………………………………………………………….…………………………………………………………………….…………………………………………………………………….…………………Head of Department:Date:Head of Department:Date:TQM OFFICE COMMENT: PART D……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………OVR FORM (PAGE 2)
    • 43SUMMARY OFSUMMARY OFLECTURE:LECTURE:• OCCOURANCEOCCOURANCE• OVR (Definition)OVR (Definition)• ADVERSE EVENTADVERSE EVENT• VARIENCEVARIENCE• NEAR MISS (& Why it should be reported)NEAR MISS (& Why it should be reported)• SENTINEL EVENTS (Definition)SENTINEL EVENTS (Definition)• “ ““ “ (Types)(Types)• “ ““ “ (policy)(policy)• “ ““ “ (Procedure)(Procedure)
    • 44SUMMARY OFSUMMARY OFLECTURE:LECTURE:• How to deal with sentinel/adverse eventHow to deal with sentinel/adverse event• Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR• Who should report /responsibilitiesWho should report /responsibilities(Employee, attending physician, immediate(Employee, attending physician, immediatesupervisor, TQM department, safety officer)supervisor, TQM department, safety officer)• OVR policyOVR policy• OVR form restrictionsOVR form restrictions• OVR form sampleOVR form sample
    • 45