Lecture by: Dr.Moha'd Ramzy Yousef Meeqat General Hospital.Madinah.KSA

1. OVR – OCCURANCE VARIANCE REPORT
IR – INCIDENT REPORT
‫االحداث؟‬ ‫عن‬ ‫االبالغ‬ ‫تقرير‬ ‫عن‬ ‫نعرف‬ ‫أن‬ ‫يجب‬ ‫ماذا‬
PREPARED BY
DR. MOHAMED RAMZY YOUSEF
HOSPITAL QUALITY COORDINATOR
QUALITY & PATIENT SAFETY
DEPARTMENT
16-07-2018 QUALITY
A WAY OF LIFE
TOGEATHER WE
CAN DO IT

2. PURPOSE
OF THE POLICY
.

3. PURPOSE
•‫لها‬ ‫يكون‬ ‫أن‬‫إيجابي‬ ‫تأثير‬‫ف‬‫ي‬
‫تحسين‬‫المرضى‬ ‫رعاية‬
‫والخدمات‬ ‫والعالج‬‫ومنع‬
‫الحوادث‬‫على‬ ‫تؤثر‬ ‫قد‬ ‫التي‬
‫المرضى‬ ‫سالمة‬.
•‫فورية‬ ‫إدارة‬ ‫وجود‬ ‫لضمان‬
‫كل‬ ‫وأن‬ ‫اللزوم‬ ‫عند‬ ‫ما‬ ‫لحادث‬
‫ي‬ ، ‫مناسب‬ ‫بشكل‬ ‫موثق‬ ‫حادث‬‫تم‬
‫والت‬ ‫األولوية‬ ‫حسب‬ ‫ترتيبه‬‫حقيق‬
‫وإدارته‬ ‫فيه‬

4. •‫حول‬ ‫العامة‬ ‫المعرفة‬ ‫لزيادة‬
‫وأسبابها‬ ‫السالمة‬ ‫أحداث‬
‫الوقاية‬ ‫واستراتيجيات‬.
•‫ثقة‬ ‫على‬ ‫للحفاظ‬‫المراجعين‬
‫والمؤسسات‬‫عمل‬ ‫في‬ ‫المعتمدة‬‫ية‬
‫االعتماد‬

5. PURPOSE
•‫وسيلة‬ ‫توفير‬‫لتحليل‬‫االتج‬‫اهات‬
‫الحوادث‬ ‫في‬‫وتحديد‬‫العوامل‬
‫للمسا‬ ‫الحوادث‬ ‫في‬ ‫تسهم‬ ‫التي‬‫عدة‬
‫في‬‫الخدمات‬ ‫تحسين‬ ‫تنفيذ‬
‫المخاط‬ ‫من‬ ‫الحد‬ ‫واستراتيجيات‬‫ر‬
‫وبالتالي‬ ،
‫تقليل‬‫المخاطر‬‫الموظف‬ ‫على‬‫ين‬
‫والزائري‬ ‫والعمالء‬ ‫والمرضى‬‫ن‬
‫والمنظمة‬.

6. DEFINITIONS
occurrence
any occurrence that is not consistent
with the routine operation which
happens at the premises, or whenever
there is an unusual or unexpected
response by a patient to standard
treatment or medical intervention,
any routine operation that adversely
affects or threatens the health or life
of patient, visitor, employee,
trainee or volunteer; or which
involves loss or damage to personal or
Hospital property.
•‫مع‬ ‫يتماشى‬ ‫ال‬ ‫حدث‬ ‫أي‬
‫الروتينية‬ ‫االجراءات‬‫التي‬
‫في‬ ‫تحدث‬،‫المستشفى‬‫عن‬ ‫أو‬‫دما‬
‫عادي‬ ‫غير‬ ‫استجابة‬ ‫هناك‬ ‫يكون‬‫ة‬
‫قبل‬ ‫من‬ ‫متوقعة‬ ‫غير‬ ‫أو‬
‫أ‬ ‫القياسية‬ ‫للمعالجة‬ ‫المريض‬‫و‬
‫عملية‬ ‫أي‬ ، ‫الطبي‬ ‫التدخل‬
‫ته‬ ‫أو‬ ‫ا‬ً‫ب‬‫سل‬ ‫تؤثر‬ ‫روتينية‬‫دد‬
‫زائر‬ ، ‫المريض‬ ‫حياة‬ ‫أو‬ ‫صحة‬
‫متطوع‬ ‫أو‬ ‫متدرب‬ ‫أو‬ ‫موظف‬ ‫أو‬
‫خسارة‬ ‫على‬ ‫تنطوي‬ ‫التي‬ ‫أو‬ ‫؛‬
‫أو‬ ‫شخصية‬ ‫لممتلكات‬ ‫ضرر‬ ‫أو‬
‫مستشفى‬

7. •An occurrence also
includes any event
might result in any
other adverse situation
that violates the code
of conduct or a claim
against the
organization.
•‫قد‬ ‫حدث‬ ‫أي‬ ‫وقوع‬ ‫يشمل‬ ‫كما‬
‫آخر‬ ‫سلبي‬ ‫موقف‬ ‫أي‬ ‫إلى‬ ‫يؤدي‬
‫ينتهك‬‫سياسةقواعد‬‫أو‬ ‫السلوك‬
‫المنظمة‬ ‫ضد‬ ‫دعوى‬.

9. DEFINITIONS
Adverse Drug/Instrument Event

10. DEFINITIONS
Adverse Event

11. •is an unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof,
not related to the natural course of a patient’s illness or
underlying condition.
•The phrase “serious physical or psychological injury”
specifically includes loss of limb or function.
•The phrase “or the risk thereof” includes any process
variation for which a recurrence would carry a significant
chance of a serious adverse outcome and includes
delays in diagnosis and treatment
DEFINITIONS
Sentinel Event (SE)
b

12. •‫أو‬ ‫بالمريض‬ ‫جسيم‬ ‫ضرر‬ ‫إلحاق‬ ‫إلى‬ ‫يؤدي‬ ‫حدث‬ ‫أي‬
‫يؤدي‬‫وفاته‬ ‫إلى‬‫الصحية‬ ‫الرعاية‬ ‫لسوء‬ ً‫نتيجة‬ ،
(‫ا‬‫ألخطاء‬‫التصرف‬ ‫أو‬ ‫البشرية‬‫فشل‬ ‫أو‬‫جمي‬ ‫أو‬ ‫النظام‬‫ع‬
‫ما‬‫سبق‬)
‫المرض‬ ‫بسبب‬ ‫وليس‬‫الذي‬ ‫األساسي‬‫منه‬ ‫يعاني‬
‫المريض‬.

13. The following events are considered
Sentinel Events even if the outcome is
not death or major permanent loss of
function, but is not limited to
• Wrong Patient.
• Surgery on the wrong patient or
body part
• Retained Instruments or a Sponge
• Hemolytic Blood Transfusion
Reaction.
• Major Medication Error Leading
to Death or Major Morbidity.
• Unexpected Death that is not
the result of the patient’s underlying
medical condition.
• Unexpected Loss of a Limb
or a Function.
• Intravascular Gas Embolism.
• Suicide , Homicide in an Inpatient
Unit.
• Infant , Child Abduction.

14. Mandatory Reportable Events Includes the
following events:
b

15. •Is an event or situation that could have resulted in an
accident, injury or illness, but did not, either by chance
or through timely intervention.
•An example of a Near Miss would be: surgical or other
procedure almost performed on the wrong patient due
to lapses in verification of patient identification but
caught at the last minute by chance.
•Near misses will receive the same level of
analysis as Adverse Events that result in
actual injury, and for learning purposes
DEFINITIONS
Near Miss

16. •: Improper or unethical conduct
or unreasonable lack of skill by
a holder of a professional or
official position, often applied
to physicians, dentists, nursing
to denote negligent or unskillful
performance of duties when
professional skills are
obligatory. Malpractice is a
cause of action for which
damage are allowed
•‫غير‬ ‫أو‬ ‫الئق‬ ‫غير‬ ‫سلوك‬
‫غير‬ ‫نقص‬ ‫أو‬ ‫أخالقي‬‫مبررفي‬
‫قبل‬ ‫من‬ ‫المهارة‬‫الممارس‬،
‫على‬ ‫تطبيقها‬ ‫يتم‬ ‫ما‬ ‫وغالبا‬
‫األسنان‬ ‫وأطباء‬ ‫األطباء‬
‫إهمال‬ ‫على‬ ‫للداللة‬ ‫والتمريض‬
‫من‬ ‫ماهر‬ ‫غير‬ ‫أداء‬ ‫أو‬
‫تكون‬ ‫عندما‬ ‫الواجبات‬
‫إلزامية‬ ‫المهنية‬ ‫المهارات‬.
•‫سوء‬‫العمل‬ ‫سبب‬ ‫هو‬ ‫التصرف‬
‫بالتلف‬ ‫يسمح‬ ‫الذي‬
DEFINITIONS
Malpractice

17. • : the differences in results obtained in measuring the
same event more than once.
• The sources of variations can be grouped into two
major classes:
– common causes and
– special causes.
• Too much variation often leads to waste and loss, such
as the occurrence of undesirable patient health outcomes
and increased cost of health services.
DEFINITIONS
Variation

18. • The policy in MGH to encourage reporting
and investigation of occurrence variance reports
in a timely manner (mandate reporting
within twenty four (24) hours of occurrence ) )for
any event that is not consistent with the standard
operations of the MOH or standard care of a
particular patient, visitor, or employee.
•MGH emphasizes that incident reporting will Not
result in disciplinary proceedings, except in
the most exceptional circumstances, for example
where there has been a breach of law, gross
negligence or professional misconduct

19. responsibility

20. Confidentiality&
Disclosure

21. Confidentiality &
Disclosure

32. b

38. Q

42. 1 2 3 4 5 6 7

43. Q. 1 ?
•What is the aims of OVR reporting?
•‫واالخطاء‬ ‫االحداث‬ ‫عن‬ ‫واالبالغ‬ ‫تقارير‬ ‫اهداف‬ ‫هي‬ ‫ما‬OVR...‫؟‬
ANSWER
Q

44. •WHAT IS SENTINEL
EVENT ?
•‫الحادث‬ ‫هو‬ ‫ما‬(‫الخطأ‬)
‫امثلة‬ ‫ذكر‬ ‫مع‬ ‫؟‬ ‫الجسيم‬..
ANSWER
Q. 2 ?
Q

45. •‫؟‬ ‫االبالغ‬ ‫واجبة‬ ‫لالحداث‬ ‫امثلة‬
EXAMPLES FOR Mandatory
Reportable Events ?
ANSWER
Q. 3 ?
Q

46. Q. 4 ?
Q

47. •WHO SHOULD TAKE
/WRITE/ REPORT
OVR?
•WHEN TO INFORM
ABOUT OVR (
TIMEFRAME ) ?
•TO WHOME ?
Q. 5 ?
Q

48. •WHEN THERE WILL BE
DISCIPLINARY ACTION ?
ANSWER
Q. 6 ?
Q

49. •WHEN SHOULD CHARGE PERSON
INFORM HEAD OF DEPARTMENT(
SUPERVISOR/SENIOR)?
ANSWER
Q. 7 ?
Q
TABLE

51. ‫المرضى‬‫وسالمة‬ ‫الجودة‬‫ادارة‬
‫العام‬‫ات‬‫الميق‬‫مستشفى‬