The document outlines the occurrence variance report system and policies for identifying, investigating, and addressing adverse and sentinel events within a hospital setting. It details roles and responsibilities for staff regarding reporting occurrences, handling of the report forms, and ensuring confidentiality. Additionally, it emphasizes the need for follow-up and monitoring of reported events to enhance patient safety and improve health service quality.

1. Occurrence Variance Reports
And Quality Methods
6/28/2010
Prepared By Dr Gamal Soliman

2. Agenda : June-2010
Parts
1- Occurrence Variance Reports-June/28
2- Sentinel and High risk Events
6/28/2010
Prepared By Dr Gamal Soliman

3. Part1
OCCURRENCE VARIANCE REPORT SYSTEM
6/28/2010
Prepared By Dr Gamal Soliman

4. Purpose
To provide a systematic, standardized
hospital-wide mechanism to identify and/or
to develop prevention /improvement
programs
6/28/2010
Prepared By Dr Gamal Soliman

5. DEFINITIONS
An Occurrence: any occurrence that is not
consistent with the routine operation which
happens at the
premises, Housing
external Activities, and transportation
Occurrence Variance Report (OVR): an
internal form _____________ used to document
the details of the occurrence/event and the
investigation of an occurrence and the corrective
actions taken.
6/28/2010
Prepared By Dr Gamal Soliman

6. Adverse Drug/Instrument Event: in
which the use of medication (drug or
biologic) at any dose, a medical
device, improper administration of
medications
On-the-job Occurrence: an
occurrence that takes place in the
Hospital or outside the premises when
the employee is carrying out
his/her duties
6/28/2010
Prepared By Dr Gamal Soliman

7. Adverse Event: are unexpected incidents, therapeutic
misadventures, iatrogenic injuries or other adverse occurrences
directly associated with care or services provided.
Some examples of adverse events include: patient falls, medication
errors, procedural errors/complications,
Sentinel Event: A “Sentinel Event” 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
Homicide
Surgery on the wrong patient
Child Abduction or discharge to the wrong family
Hemolytic Blood Transfusion
6/28/2010
Prepared By Dr Gamal Soliman

8. Near Miss: Is an event or situation that could
have resulted in an accident, Injury or illness,
Malpractice: 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
6/28/2010
Prepared By Dr Gamal Soliman

9. Variation: the differences in results
obtained in measuring the same event
more than once.
Grouped into common causes and special
causes. Too much variation often leads to
waste and loss -- Giving rise to
undesirable patient health outcomes and
increased cost of health services.
6/28/2010
Prepared By Dr Gamal Soliman

10. RESPONSIBILITY
1- It is the responsibility of the person in charge to assure
the stability of any injury in the first priority and have the
OVR completed. to assure the stability of any injury in the
first priority and have the OVR completed.
2- The Employee who witness or discover an occurrence
has the professional responsibility for:
Immediately notifying:
The physician on call if the occurrence
involves any question of patient or
employee injury or harm.
And The area supervisor.To initiate the OVR
6/28/2010
Prepared By Dr Gamal Soliman

11. 3- The Supervisor is responsible for:
Ensuring that all employees are aware of
OVR system as well as Conducting
immediate follow-up of the occurrence and
Ensuring thorough and accurate
completion of the OVR form and
Forwarding the completed OVR form
within 72 hours and finally Conducting any
further investigation
6/28/2010
Prepared By Dr Gamal Soliman

12. 4- The Physician: she/he is responsible to
document a brief statement of his/her
action(s) on the OVR form immediately upon
completion the patient / employee
examination
5-QM Department is responsible for :
Monitoring all OVR(s) for follow –up, Trending
and preparing a monthly summary of all
reported occurrences, Submitting a quarterly
report to the TQM and Maintaining a file of all
OVR submitted to the TQM office for 3 years
6/28/2010
Prepared By Dr Gamal Soliman

13. 6-The Safety Officer
( need to be employed)
is responsible for:
Investigating all safety related
occurrences, Activating a Review Team,
Documenting the results of investigation
and corrective action , Returning the
completed form to the TQM office,
Reviewing monthly summary data
6/28/2010
Prepared By Dr Gamal Soliman

14. POLICY
It is the responsibility of all employees to
immediately report the details of any occurrence
and This report is to be used to identify the facts
surrounding the occurrence and will not be used
to criticize or speculate on actions of the staff
involved
6/28/2010
Prepared By Dr Gamal Soliman

15. POLICY
The OVR form shall not be
photocopied or placed in the medical
record. The terms “incident” and
“error” shall not be used in the
medical
6/28/2010
Prepared By Dr Gamal Soliman

16. POLICY
It is the responsibility of patient Safety manager to
supply the Safety Committee with a quarterly
summary
Confidentiality All OVR shall be handled and
maintained in a confidential manner,
OVR shall not be duplicated, with exception of the
TQM department
The information contained in the OVR form cannot
and shall not be used against any individual as the
sole basis for disciplinary action.
Hospital staff is not at liberty to discuss the contents
of an OVR or the events and circumstances relative
to the occurrence either with patient, visitor or other
members
6/28/2010
Prepared By Dr Gamal Soliman

17. PROCEDURE
General instructions: (guidelines how to use
the Form)
Use of OVR template.
If not possible use blue ink. Avoid pencils,
in clear legible handwriting
Write objective view and comments. Avoid
personal opinions.
The OVR form consists of the following
sections
Upper right corner: Patient Information
6/28/2010
Prepared By Dr Gamal Soliman

18. Occurrence Details:
(by the person witnessed / affected by
the occurrence)
Person(s) affected
Affected employee information
Occurrence brief description
Immediate action taken
Witness(es) Information
Supervisor Notification (included –
decision of sentinel event)
Physician Follow Up Notification
6/28/2010
Prepared By Dr Gamal Soliman

19. Severity of Injury:
Slight / minor treatment: the incident
resulted in abrasion, reddening of the
skin, a bruise or other apparently
minor damage to tissue. The
treatment required was non-invasive
for e.g. topical ointment, dressing or
ice packs. Medication incidents that
may require monitoring such as
changes in vital signs or lab tests.
6/28/2010
Prepared By Dr Gamal Soliman

20. Moderate injury: the incident resulted in
hemorrhage, tissue impairment and
required clinical intervention. For e.g.
suturing, first and second degree burns.
Medication incidents with potential for
serious outcomes that require intervention
and monitoring.
Serious injury: the incident resulted in
fracture, hemorrhage, aspiration, third
degree burns, serious drug reaction or the
incident resulted in admission to hospital (if
outpatient), transfer to critical care area, or
increase in length of stay (inpatient).
6/28/2010
Prepared By Dr Gamal Soliman

21. Death
Integrated Occurrence Strategy (as
needed) Follow up, by responsible
person/department, to include:
recommendations
TQM office comments
Type of occurrences
Contributing factors

6/28/2010
Prepared By Dr Gamal Soliman

22. Part 2
Sentinel and High risk Events
6/28/2010
Prepared By Dr Gamal Soliman

23. PURPOSE
1.
identify Sentinel Events
2.
make appropriate individuals aware of S.E.
3.
investigate and understand the causes
4.
make changes in the hospital systems to
reduce the probability of S.E.
6/28/2010
Prepared By Dr Gamal Soliman

24. Definitions
Action Plan: is the product of the Root cause
Analysis that identifies the strategies to reduce
the probability of S.E. in the future.
CBAHI : Central Board of Accreditation for
Healthcare Institutions
Policy : The “Policy” is this Sentinel and Root
Cause Analysis policy
Root Cause Analysis : a process for identifying
the causal factor(s) that underlie variation in
performance including the occurrence or possible
occurrence of a S.E.
6/28/2010
Prepared By Dr Gamal Soliman

25. Sentinel Event: is an unexpected occurrence involving
death or serious physical or psychological injury not
related to the natural course of a patient’s illness
including delays in diagnosis and treatment
Example Types,
Suicide
Homicide
Surgery on the wrong patient or body part
Impairment (major/permanent loss of bodily
function
Any unexpected death that is not the result of
the patient’s underlying medical condition
 Rape
 Child Abduction
gg
6/28/2010
Prepared By Dr Gamal Soliman

26. Task Force : is the subcommittee
appointed by the Committee to:
(1)investigate an occurrence or
process variation
(2) (2) determine whether such occurrence
or process variation meets the definition
of a Sentinel Event,
(3) complete a thorough and credible Root Cause
Analysis and resulting Action Plan describing the
hospital’s risk reduction strategies
6/28/2010
Prepared By Dr Gamal Soliman

27. Responsibility
1- Creation of Committee – S.E. Committee
2- Composition of Committee
Administrator
Medical Director
Director of Nursing
Assistant Administrator for Clinical Services
Ex-officio members
Chief Legal Officer
Healthcare Risk Manager
Risk manager
Designated staff persons
6/28/2010
Prepared By Dr Gamal Soliman

28. Duties of the Committee
Investigate an occurrence or process
variation
Determine whether such occurrence or
process variation meets the definition of a
Sentinel Event
Ensure completion of a thorough and
credible Root Cause Analysis and resulting
Action Plan
6/28/2010
Prepared By Dr Gamal Soliman

29. PROCEDURE
Application of Policy
Identification of Sentinel event
Appointment of Task Force
6/28/2010
Prepared By Dr Gamal Soliman

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