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10 ovr reporting handbook

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Lecture by :

Lecture by :
DR . MOHAMED RAMZY YOUSSEF
ER RESIDENT
QUALITY COORDINATOR , QPSD,MGH

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    10 ovr reporting handbook 10 ovr reporting handbook Presentation Transcript

    • Occurrence Variance Report and Sentinel Reporting System DR . MOHAMED RAMZY YOUSSEF ER RESIDENT QUALITY COORDINATOR , QPSD,MGH ‫عن‬ ‫التبليغ‬ ‫ونظام‬ ‫الحادث‬ ‫تقرير‬ ‫الخطورة‬ ‫بالغة‬ ‫الحوادث‬
    • ‫الغرض‬Purpose Occurrence Variance Report is used to help identify areas needing improvement or recognition ‫تقرير‬ ‫يستخدم‬ ‫للمساعدة‬ ‫الحادث‬ ‫ومعرفة‬ ‫تحديد‬ ‫في‬ ‫السقسام‬ ‫حاجة‬ ‫.للتطوير‬
    •  Occurrence Variance Report (OVR) are internal forms used to document the details of the incident and the investigation of an occurrence and the corrective actions taken. •‫عبارة‬ ‫الحوادث‬ ‫تقارير‬ ‫داخلية‬ ‫استمارات‬ ‫عن‬ ‫تفاصيل‬ ‫لتوثيق‬ ‫تستخدم‬ ‫ذلك‬ ‫في‬ ‫والتحقيق‬ ‫الحادث‬ ‫الجراء‬ ‫واتخاذ‬ .‫اللمزم‬ ‫التصحيحي‬
    • ‫تستخدم؟‬ ‫متى‬‫؟‬When to use  Injury to visitors or volunteers while on the hospital premises .‫المستشفى‬ ‫بمبنى‬ ‫تواجدهم‬ ‫أثناء‬ ‫المتطوعين‬ ‫أو‬ ‫الزوار‬ ‫إصابة‬  Any incident which is not consistent to routine patient care .‫بالمريض‬ ‫العناية‬ ‫روتين‬ ‫مع‬ ‫تتعارض‬ ‫حادثة‬ ‫أي‬
    •  Occurrences not consistent with routine operation of facility and /or adversely affects, threatens the health or life of patient, visitor, employee, student or volunteer. ‫أو‬ ‫الروتينيية‬ ‫المسيتشفى‬ ‫عمليات‬ ‫ميع‬ ‫المتعارضية‬ ‫الحوادث‬ ‫أو‬ ‫الزائر‬ ‫أو‬ ‫المريض‬ ‫حياة‬ ‫أو‬ ‫صحة‬ ‫يهدد‬ ‫وما‬ ‫السلبية‬ ‫المؤثرات‬ .‫المتطوع‬ ‫أو‬ ‫الطالب‬ ‫أو‬ ‫الموظف‬  Loss or damage to personal or hospital property. .‫المستشفى‬ ‫ممتلكات‬ ‫أو‬ ‫الخاصة‬ ‫الممتلكات‬ ‫تضرر‬ ‫أو‬ ‫فقدان‬
    • ‫يبلغ؟؟؟‬ ‫أن‬ ‫عليه‬ ‫يجب‬ ‫من‬ Who should reports  Everybody ‫كل‬ ‫على‬ ‫يجب‬ /‫الجميع‬ . ‫التبليغ‬ ‫شخص‬
    • What to report ‫تبلغ؟‬ ‫ماذا‬ ‫عن‬  Miscommunication ‫فهم‬ ‫سوء‬  Accidental needle prick ‫بالبرة‬ ‫مقصود‬ ‫غير‬ ‫جرح‬  Absconded ‫هروب‬  Blood extraction ‫دم‬ ‫سحب‬  Problem in cleanliness ‫نظافة‬ ‫مشكلة‬  Medicines not transcribed ‫الطبية‬ ‫الوصفة‬ ‫كتابة‬ ‫عدم‬  No response to call ‫للنداء‬ ‫الستجابة‬ ‫عدم‬
    • What to report ‫تبلغ؟‬ ‫ماذا‬ ‫عن‬  Violation in standard precaution ‫الوسقائية‬ ‫المعايير‬  Delays in:_______‫في‬ ‫:تأخير‬  Non-availability of supplies/forms ‫النموذج‬ ‫أو‬ ‫المخزون‬ ‫توفر‬ ‫عدم‬  Expired blood‫الدم‬ ‫صلحية‬ ‫انتهاء‬  Wrong patient identification‫للمريض‬ ‫تعريف‬ ‫خطأ‬  Other (specify:‫)حدد‬ ‫)أخرى‬
    • Policy ‫السياسة‬ 1. Report the details of any occurrence, which has an impacts in the care of patient. 1‫على‬ ‫يهدد/يؤثير‬ ‫حادث‬ ‫أيي‬ ‫عين‬ ‫التفاصييل‬ ‫بإعطاء‬ ‫سقيم‬ . .‫بالمريض‬ ‫العناية‬
    • 2. OVR Form will be initiated immediately after the incident. And submit it to your immediate supervisor within the current work shift. 2‫بعد‬ ‫را‬ً‫ا‬ ‫فو‬ ‫تعبأ‬ ‫أن‬ ‫يجب‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ . .‫العمل‬ ‫فترة‬ ‫خل ل‬ ‫رئيسك‬ ‫إلى‬ ‫تسلم‬ ‫وأن‬ ‫الحادث‬
    • 3. The report will not be used to criticize or blame the actions of the staff involved. 3‫إلقاء‬ ‫او‬ ‫لنقد‬ ‫التقرير‬ ‫يستخدم‬ ‫ل‬ ‫أن‬ ‫يجب‬ . ‫عنه‬ ‫المبلغ‬ ‫القسم‬ ‫على‬ ‫اللوم‬
    • 4. Corrective actions shall be taken to minimize risk of injury and adverse outcomes. Corrective action(s) shall be documented. 4‫خطر‬ ‫من‬ ‫ليقلل‬ ‫يتخذ‬ ‫أن‬ ‫يجب‬ ‫التصحيحي‬ ‫.الجراء‬ ‫والجراء‬ .‫لذلك‬ ‫المعاكسة‬ ‫والردود‬ ‫الضرر‬ ‫في‬ ‫توثيقه/تسجيله‬ ‫يتم‬ ‫ان‬ ‫يجب‬ ‫التصحيحي‬ .‫المستندات‬ /‫السجلت‬
    • 5. The Occurrence report shall not be placed in the medical record (Patient File) nor in Employee File. 5‫في‬ ‫الحادث‬ ‫تقرير‬ ‫يوضع‬ ‫ل‬ ‫ان‬ ‫يجب‬ . ‫أو‬ (‫المرضى‬ ‫)ملفات‬ ‫الطبية‬ ‫السجلت‬ .‫الموظف‬ ‫ملف‬ ‫في‬
    • 6. Confidentiality: 6. ‫ي:ه‬ّ‫ه‬‫:السر‬ 6.1 OVR reports will be handled in outmost confidentiality. a.‫تامة‬ ‫سرية‬ ‫في‬ ‫تسلم‬ ‫أن‬ ‫يجب‬ ‫الحوادث‬ ‫تقارير‬ 6.2 OVR should not be duplicated with exception of the TQM department. a.‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬ ‫باستثناء‬ ‫ينسخ‬ ‫ل‬ ‫أن‬ ‫يجب‬ ‫الحادث‬ ‫تقرير‬ 6.3 The information contained in the OVR form cannot and will not be used against any individual as basis for any disciplinary action. ‫أي‬ ‫ضد‬ ‫تستخدم‬ ‫ولن‬ ‫يمكن‬ ‫ل‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫في‬ ‫الموثقة‬ ‫المعلومات‬ -‫جـ‬ ‫تأديبي‬ ‫إجراء‬ ‫لي‬ ‫شخص‬
    • 6.4 Hospital staff are NOT allowed to discuss the contents of an OVR or the events and circumstances relative to the occurrence either with patient, visitor or other members of the staff, unless clarifying facts under investigation with the proper authorities. -‫د‬‫ل‬‫والدحداث‬ ‫المحتوى‬ ‫يناقشوا‬ ‫أن‬ ‫المستشفى‬ ‫لموظفي‬ ‫يحق‬ ‫أو‬ ‫الزائر‬ ‫او‬ ‫المريض‬ ‫مع‬ ‫سواء‬ ‫بالحادث‬ ‫المتعلقة‬ ‫والظروف‬ ‫دراسة‬ ‫عند‬ ‫الحقائق‬ ‫توضيح‬ ‫عند‬ ‫إل‬ ،‫الرخرين‬ ‫المستشفى‬ ‫موظفي‬ .‫المعنيين‬ ‫المسئولين‬ ‫ومع‬ ‫المشكلة/الحادث‬
    • 6.5 Discussion of general issues on OVR for instructional or education purposes with view to improving patient care is, however strongly encouraged. ‫الحادث‬ ‫تقرير‬ ‫في‬ ‫العامة‬ ‫المسائل‬ ‫مناقشة‬ ‫أن‬ -‫هـ‬ ‫العناية‬ ‫لتطوير‬ ‫التعليم‬ ‫أو‬ ‫الرشاد‬ ‫لرغراض‬ .‫بشدة‬ ‫تشجيعها‬ ‫يتم‬ ‫بالمريض‬
    • 6.7 Names of involved/ concerned person should not be used. ‫القضية‬ ‫ب:ه‬ ‫المتعلقة‬ ‫الشخص‬ ‫اسم‬ ‫يستخدم‬ ‫ل‬ ‫أن‬ ‫يجب‬ -‫و‬ .‫فقط‬ ‫تعريف:ه‬ ‫رقم‬ ‫يستخدم‬ ‫بل‬
    • Occurrence Reporting flowchart ‫الحادث‬ ‫عن‬ ‫:التبليغ‬ Incident occurs ‫الحادث‬ ‫وقوع‬ Awareness of the occurrence ‫الحادثة‬ ‫عن‬ ‫التبليغ‬ Occurrence Variance Report Form is completed by the person witnessed/affected by the occurrence (Part A: Occurrence Details) and forward the duplicate copy to TQM Dept. ‫الحادثة‬ ‫من‬ ‫شهد/تضرر‬ ‫الذي‬ ‫الشخص‬ ‫قبل‬ ‫من‬ ‫تعبأ‬ (‫الشاملة‬ ‫الجودة‬ ‫ادارة‬ ‫قسم‬ ‫إلى‬ ‫ترسل‬ ‫الحادث(و‬ ‫تفاصيل‬ ‫أ‬ :‫الجزء‬ Immediate Supervisor evaluates occurrence if it meets the Sentinel Event criteria (Part B: Immediate Supervisor Notification) ‫الخطورة‬ ‫بالغة‬ ‫الحادثة‬ ‫كانت‬ ‫إذا‬ ‫ما‬ ‫المباشر‬ ‫المشرف‬ ‫يقيم‬ ‫المباشر‬ ‫الرئيس‬ ‫تبليغ‬ (‫الجزء)ب‬
    • Meets Sentinel Event Criteria ‫معايير‬ ‫توافق‬ ‫الطارئة‬ ‫الحادثة‬ Refer to Sentinel Event Committee ‫الحوادث‬ ‫لجنة‬ ‫تبليغ‬ ‫الطارئة‬ Supervisor/designee carries out required investigation/corrective actions (Part D: Action Taken) ‫التحقيق‬ ‫مسئولية‬ ‫المشرف‬ ‫يتحمل‬ ‫المتخذ‬ ‫د:الجراء‬ ‫)الجزء‬ ‫)المطلوب‬ NoYes If case of injury Physician should be informed and completes the follow up as needed (Part C: Physician Follow-up) (‫ج‬ ‫مطلوب)الجزء‬ ‫هو‬ ‫كما‬ ‫بالمتابعة‬ ‫يقوم‬ ‫المبلغ‬ ‫الطبيب‬ ‫الصابة‬ ‫دحالة‬ ‫في‬ ‫الطبيب‬ ‫متابعة‬ Other services/dept. involved ‫المعنية‬ ‫الرخرى‬ ‫القسام‬ Document action taken on the OVR form (Part D) by the Immediate Supervisor ‫على‬ ‫وسجل:ه‬ ‫محتاج‬ ‫هو‬ ‫كما‬ ‫التصحيحي‬ ‫الجراء‬ ‫أتخذ‬ ‫المباشر‬ ‫الرئيس‬ ‫بواسطة‬ (‫د‬ ‫)الجزء‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ No Yes
    • Immediate Supervisor forwards the original copy of OVR and refer the incident to the Supervisor/ HOD of the involved dept. ‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫الى‬ ‫نسخ:ه‬ ‫وترسل‬ ‫المسئول‬ ‫القسم‬ ‫عن‬ ‫الجوده‬ ‫تطوير‬ ‫لجنة‬ ‫مشرف‬ ‫بلغ‬ Involved dept. Supervisor/ HOD investigate & document corrective action taken and his/her recommendations to prevent recurrence on the OVR form (Part D) ‫وإجراءه‬ ‫متابعت:ه‬ ‫ويسجل‬ ‫بالتحقيق‬ ‫يقوم‬ ‫المسئوول‬ ‫القسم‬ ‫مشرف‬ ‫)د‬ ‫الجزء‬ ‫في‬ ‫الحادث‬ ‫تقرير‬ ‫إستمارة‬ ‫على‬ ‫)وتوصيات:ه‬ Inform initiating dept. of the action taken ‫المسئول‬ ‫القسم‬ ‫ابل غ‬ ‫المتخذ‬ ‫بالجراء‬ Supervisor forwards original copy of OVR to TQM Dept. ‫قسم‬ ‫الى‬ ‫يرسل‬ ‫الجودة‬ ‫ادارة‬ ‫الشاملة‬ TQM follows up as needed ‫ادارة‬ ‫تقوم‬ ‫بالمتابعة‬ ‫الجوده‬ ‫اللمزمة‬ TQM trends all OVRs ‫الجودة‬ ‫إدارة‬ ‫تقوم‬ ‫بتوجي:ه‬ ‫الشاملة‬ ‫تقارير‬ ‫كل‬ ‫الحوادث‬ TQM forwards quarterly reports to concerned areas, QMC & Safety Committee‫ادارة‬ ‫ترسل‬ ‫تقارير‬ ‫الشاملة‬ ‫الجودة‬ ‫كل‬ ‫دورية‬3‫للقسام‬ ‫أشهر‬ ‫الجودة‬ ‫ادارة‬ ‫لجنة‬ ،‫المعنية‬ ‫السلمة‬ ‫وإدارة‬
    • RESPONSIBILITIES ‫المسئوليات‬ 1. Immediate Supervisors ‫الدارة‬ ‫وموظفي‬ ‫:المشرفين‬ - Consultation with the involved employee(s). .‫المعنيين‬ ‫بالموظفين‬ ‫الجتماع‬ - -Resolution of problems should take place when possible within and between departments ‫ممكن‬ ‫وقت‬ ‫اقرب‬ ‫في‬ ‫توضع‬ ‫ان‬ ‫يجب‬ ‫دحيث‬ ‫للمشاكل‬ ‫الحلول‬ ‫وضع‬ - .‫القسام‬ ‫بين‬
    • -Ensuring that all employees are aware of OVR Reporting System; how to report and the steps by steps procedure on how to complete the form. -‫التبليغ‬ ‫وكيفية‬ ‫الحوادث‬ ‫تقرير‬ ‫لنظام‬ ‫الموظفين‬ ‫معرفة‬ ‫من‬ ‫التأكد‬ .‫بخطوة‬ ‫رخطوة‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫وتعبئة‬ - Conduct immediate action and follow up after the incident occurs. -.‫الحادث‬ ‫وقوع‬ ‫بعد‬ ‫مباشرة‬ ‫فورية‬ ‫بمتابعة‬ ‫قم‬
    • - Document on the OVR the actions taken and/or any corrective measures, taken to prevent the recurrence of the event. -‫مقاييس‬ ‫أي‬ ‫او‬ ‫المتخذ‬ ‫الجراء‬ ‫الحادث‬ ‫تقرير‬ ‫في‬ ‫اكتب‬ .‫الحادث‬ ‫هذا‬ ‫مثل‬ ‫دحدوث‬ ‫لتمنع‬ ‫اتخذت‬ ‫تصحيحية‬  Evaluates incident if meets sentinel event criteria.  ‫الخطورة‬ ‫بالغة‬ ‫الحادثة‬ ‫معايير‬ ‫يوافق‬ ‫كان‬ ‫إذا‬ ‫الحادث‬ ‫قيم‬
    • - Forward the completed (original) OVR report form to the Total Quality Management office within 72 hours (3 days) of the occurrence. -‫إدارة‬ ‫مكتب‬ ‫إلى‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫لم‬ّ‫ه‬‫س‬ ‫رخلل‬ ‫الشاملة‬ ‫الجودة‬72‫من‬ (‫أيام‬ ‫)ثلث‬ ‫ساعة‬ .‫الحادث‬
    • - Conduct any further investigation and document, report investigated findings upon request of the Hospital Administration the Quality Management Committee or the Safety Committee. ‫على‬ ‫بناء‬ ‫التحقيق‬ ‫موجودات‬ ‫وتوثيق‬ ‫إضافي‬ ‫تحقيق‬ ‫أي‬ ‫بعمل‬ ‫قم‬ .‫السلمة‬ ‫لجنة‬ ‫او‬ ‫الجودة‬ ‫ادارة‬ ‫لجنة‬ ‫المستشفى‬ ‫إدارة‬ ‫من‬ ‫طلب‬
    • 2. The employee who witnesses or discovers 2:‫الحادث‬ ‫اكتشفوا‬ ‫او‬ ‫شاهدو‬ ‫الذين‬ ‫.الموظفين‬ 2.1 Immediate notification of attending physician in case of injury and Immediate Supervisor .‫القسم‬ ‫ومشرف‬ ‫المناوب‬ ‫للطبيب‬ ‫المباشر‬ ‫العل م‬ -
    • 3. Attending Physician 4:‫الطباء‬ . - Complete and document his/her action(s) on the OVR form immediately upon carrying out his examination and/or the required treatment or care. ‫إستمارة‬ ‫على‬ ‫المتخذ‬ ‫الجراء‬ ‫عن‬ ‫مختصر‬ ‫ملخص‬ ‫توثيق‬ ‫اداء‬ ‫أو‬ ‫اختباره‬ ‫انهاء‬ ‫فور‬ ‫مباشرة‬ ‫الحادث‬ ‫تقرير‬ . ‫المطلوبة‬ ‫المعالجة‬
    • 5. The Total Quality Management Department is responsible for: - Monitoring all OVR for follow up. - Trending and preparing a monthly summary. ‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬ ‫إن‬ ‫عن‬ ‫:مسئول‬ -‫الحوادث‬ ‫تقارير‬ ‫كل‬ ‫متابعة‬ .‫المكتملة‬ ‫غير‬ -.‫شهري‬ ‫ملخص‬ ‫ووضع‬ ‫تجهيز‬
    • - Submitting a quarterly report to the Quality Management Committee for discussion and what action can be done in the future to avoid recurrence. - Upkeep the file ‫مسئول‬ ‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬ ‫إن‬ ‫:عن‬ -‫لجنة‬ ‫إلى‬ ‫سنوي‬ ‫ربع‬ ‫تقرير‬ ‫تسليم‬ ‫ووضع‬ ‫للمناقشة‬ ‫الجودة‬ ‫إدارة‬ ‫لتفادي‬ ‫المستقبليه‬ ‫المخططات‬
    • 5. The Safety Officer  Investigate all safety related incidents  Organize a review team of selected Safety Committee members to investigate critical safety related occurrences. 6:‫السلمة‬ ‫مسئول‬ - -.‫الحادث‬ ‫متعلقات‬ ‫جميع‬ ‫سلمة‬ ‫من‬ ‫التحقق‬ -‫السلمة‬ ‫لجنة‬ ‫اعضاء‬ ‫من‬ ‫مراجعه‬ ‫فريق‬ ‫تنظيم‬ .‫بالحادث‬ ‫المتعلقة‬ ‫السلمة‬ ‫ملظحظات‬ ‫لبداء‬
    • 6. The Safety Officer - Document the results of investigation and corrective action taken on the OVR form and forwards it to the TQM. 6:‫السلمة‬ ‫مسؤول‬ - -‫التصحيحية‬ ‫والجراءات‬ ‫التحقيق‬ ‫نتائج‬ ‫بتوثيق‬ ‫قم‬ ‫قسم‬ ‫إلى‬ ‫وسلمها‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫في‬ ‫المتخذة‬ .‫الشاملة‬ ‫الجودة‬ ‫إدارة‬
    • EQUIPMENTS AND FORMS ‫والنماذج‬ ‫الجهزة‬ 1. Occurrence Variance Report Form 1..‫الحادث‬ ‫تقرير‬ ‫نموذج‬
    • Sentinel Event ‫متوقعة‬ ‫الغير‬ ‫الخطيرة‬ ‫الحوادث‬  An unexpected occurrence involving death, serious physical or psychological injury to the patient ‫الموت‬ ‫مثل‬ ‫المتوقعة‬ ‫غير‬ ‫الخطيرة‬ ‫الحوادث‬ .‫للمرضى‬ ‫الخطيرة‬ ‫والنفسية‬ ‫الجسدية‬ ‫والضرار‬
    • Reportable Cases ‫عنها‬ ‫التقرير‬ ‫يجب‬ ‫ظحالت‬ • An unanticipated death • Major permanent loss of limb or function, not related to the patient’s illness or underlying condition • Infant abduction . ‫المتوقع‬ ‫غير‬ ‫الموت‬ ‫وظيفة‬ ‫او‬ ‫عضو‬ ‫فقدان‬ ‫علقة‬ ‫له‬ ‫ليس‬ ‫جسدية‬ .‫تنويمه‬ ‫أو‬ ‫المريض‬ ‫بمرض‬ ‫مولود‬ ‫اختطاف‬
    • Reportable Cases ‫عنها‬ ‫التقرير‬ ‫يجب‬ ‫ظحالت‬  suicidal attempt within the hospital premises.  Rape  Physical assault of a patient, staff or visitor  Infant discharge to the wrong family ‫داخل‬ ‫النتحار‬ ‫محاولة‬ .‫المستشفى‬ ‫العتداء‬ ‫على‬ ‫الجسدي‬ ‫العتداء‬ ‫أو‬ ‫الموظف‬ ‫أو‬ ‫المريض‬ .‫الزائر‬ .‫الخطأ‬ ‫للعائلة‬ ‫طفل‬ ‫تسليم‬
    • Reportable Cases ‫عنها‬ ‫التقرير‬ ‫يجب‬ ‫ظحالت‬ • Significant hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities • Surgery on the wrong patient or body part • Significant Medication errors (Overdose causing death to patient.) •‫للمريض‬ ‫عملية‬ ‫إجراء‬ ‫المنطقه‬ ‫في‬ ‫أو‬ ‫الخاطئ‬ .‫الخاطئة‬ •‫الواضحة‬ ‫العلج‬ ‫أخطاء‬ ‫المسببه‬ ‫الزائدة‬ ‫)كالجرعة‬ .(‫المريض‬ ‫لوفاة‬
    • Sentinel Event ReportingProcess ‫متوقعة‬ ‫الغير‬ ‫الخطرة‬ ‫الحوادث‬ ‫عن‬ ‫التبليغ‬ ‫عملية‬ 1. Immediate notification 1:‫المباشر‬ ‫التبليغ‬ .  Departmental Quality Improvement Designee/Coordinator (QIC/Designee) .‫القسام‬ ‫جودة‬ ‫تحسين‬ ‫فريق‬ ‫منسق‬ / ‫ممثل‬
    • 2. The QIC/D will notify 2:‫لغ‬ّ‫غ‬‫يب‬ ‫سوف‬ ‫المصمم‬ / ‫الجودة‬ ‫تحسين‬ ‫فريق‬ .  Head of the Department .‫القسم‬ ‫رئيس‬ -
    • 3. The QID/C will call or bleep (454) Quality Improvement Coordinator by phone or in person. ‫بإدارة‬ ‫الجودة‬ ‫منسق‬ ‫بإبل غ‬ ‫يقوم‬ ‫الجودة/المنسق‬ ‫ممثل‬ ‫الرقم‬ ‫طلب‬ ‫طريق‬ ‫عن‬ ‫الشاملة‬ ‫الجودة‬454‫أو‬ .‫مباشرة‬ ‫مخاطبته‬
    • 4. Occurrence Report should be submitted to the Quality Improvement Coordinator 4‫يسلم‬ ‫ان‬ ‫يجب‬ ‫الحادث‬ ‫تقرير‬ . .‫الجودة‬ ‫تحسين‬ ‫منسق‬ ‫إلى‬
    • 5. Quality Improvement Coordinator will conduct an investigation and interview the involved person and/or any witness of the event. ‫منسق‬ ‫يقوم‬ ‫سوف‬ ‫بعمل‬ ‫الجودة‬ ‫تحسين‬ ‫ومقابلة‬ ‫تحقيق‬ ‫عنه‬ ‫المبلغ‬ ‫الشخص‬ ‫على‬ ‫شاهد‬ ‫أي‬ ‫أو‬ ‫الحادث‬
    • 6. Quality Improvement Coordinator will notify the Sentinel Event Committee and convene for a meeting. 6‫الجودة‬ ‫تحسين‬ ‫منسق‬ ‫يقوم‬ ‫.سوف‬ ‫الغير‬ ‫الخطيرة‬ ‫الحوادث‬ ‫لجنة‬ ‫بتبليغ‬ .‫لذلك‬ ‫اجتماعا‬ ‫وتعقد‬ ‫متوقعه‬
    • 7. Root Cause Analysis will be initiated and facilitated. 7‫السباب‬ ‫.تحليل‬‫يوضح‬ ‫سوف‬ ‫والنتائج‬ .‫ويقدم‬
    • 8. Action plan will be designed as appropriate and implemented immediately. 8‫الولوية‬ ‫حسب‬ ‫على‬ ‫عمل‬ ‫خطة‬ ‫توضع‬ ‫.سوف‬ .‫الفور‬ ‫على‬ ‫وتطبق‬
    • 9. All investigation and conclusion documentation will be in the custody of the Total Quality Management Department and remained confidential. 9‫في‬ ‫محفوظة‬ ‫تظل‬ ‫سوف‬ ‫الموثقة‬ ‫ونتائجه‬ ‫التحقيق‬ ‫كل‬ . .‫ة‬ً. ‫بسري‬ ‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬
    • 10. Follow up assessment will be conducted by SEC and the concerned department within six (6) months of the event 10‫الحوادث‬ ‫لجنة‬ ‫قبل‬ ‫من‬ ‫تكمل‬ ‫سوف‬ ‫القضية‬ ‫متابعة‬ . ‫أشهر‬ ‫ستة‬ ‫خل ل‬ ‫المعني‬ ‫القسم‬ ‫مع‬ ‫متوقعة‬ ‫الغير‬ ‫الخطيرة‬ .‫الحادث‬ ‫من‬