The document outlines the policies and procedures for reporting occurrences and sentinel events at a hospital using Occurrence Variance Reports (OVR). It states that OVRs should be completed by staff to document any incidents, injuries, or issues. Sentinel events involving major patient harm or death require special reporting to the Quality Improvement Coordinator and Sentinel Event Committee for a root cause analysis and action plan. The Total Quality Management Department monitors OVRs, identifies trends, and reports to relevant committees to prevent future issues. All occurrence reporting and investigation information is kept confidential by the TQM department.

1. Occurrence Variance
Report and Sentinel
Reporting System
Ms. Eleanor L. Zamora
Clinical Quality Coordinator – Risk
Manager
Total Quality Management Department

2. Purpose
Occurrence
Variance Report
is used to help
identify areas
needing
improvement or
recognition
.

3.  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.
•

4. When to use
 Injury to visitors or volunteers while
on the hospital premises

 Any incident which is not consistent
to routine patient care


5.  Occurrences not consistent with routine
operation of facility and /or adversely
affects, threatens the health or life of
patient, visitor, employee, student or
volunteer.

 Loss or damage to personal or hospital
property.


6. Who should reports
 Everybody


7. What to report
 Miscommunication
 Accidental needle prick
 Absconded
 Blood extraction
 Problem in cleanliness
 Medicines not transcribed
 No response to call

8. What to report
 Violation in standard precaution
 Delays in:_______:
 Non-availability of supplies/forms
 Expired blood
 Wrong patient identification
 Other (specify:)

9. Policy
1. Report the details of any
occurrence, which has an impacts
in the care of patient.
1

10. 2. OVR Form will be initiated
immediately after the
incident. And submit it to
your immediate supervisor
within the current work shift.
2

11. 3. The report will not be
used to criticize or blame
the actions of the staff
involved.
3

12. 4. Corrective actions shall be
taken to minimize risk of
injury and adverse outcomes.
Corrective action(s) shall be
documented.
4

13. 5. The Occurrence report
shall not be placed in
the medical record
(Patient File) nor in
Employee File.
5

14. 6. Confidentiality: 6. :
6.1 OVR reports will be handled in outmost
confidentiality.
a.
6.2 OVR should not be duplicated with
exception of the TQM department.
a.
6.3 The information contained in the OVR
form cannot and will not be used against
any individual as basis for any disciplinary
action.

15. 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.

16. 6.5 Discussion of general issues
on OVR for instructional or
education purposes with view
to improving patient care is,
however strongly encouraged.

17. 6.7 Names of involved/
concerned person should not be
used.

18. Occurrence Reporting flowchart
: Incident occurs
Awareness of the occurrence
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.
(
Immediate Supervisor evaluates occurrence if it meets the
Sentinel Event criteria (Part B: Immediate Supervisor
Notification)

19. Meets Sentinel
Event Criteria
Refer to Sentinel
Event Committee
Supervisor/designee carries
out required
investigation/corrective
actions (Part D: Action Taken)
)
NoYes
If case of injury Physician should be informed and completes
the follow up as needed (Part C: Physician Follow-up)
Other
services/dept.
involved
Document action taken on the OVR form (Part D)
by the Immediate Supervisor No
Yes

20. Immediate Supervisor forwards the original copy of OVR and
refer the incident to the Supervisor/ HOD of the involved dept.
Involved dept. Supervisor/ HOD investigate &
document corrective action taken and his/her
recommendations to prevent recurrence on
the OVR form (Part D)
)
Inform initiating dept.
of the action taken
Supervisor
forwards
original copy of
OVR to TQM
Dept.
TQM follows
up as
needed
TQM trends all
OVRs
TQM forwards
quarterly reports to
concerned areas,
QMC & Safety
Committee3

21. RESPONSIBILITIES
1. Immediate Supervisors :
- Consultation with the involved
employee(s).
-Resolution of problems should take
place when possible within and
between departments

22. -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.
-
- Conduct immediate action and follow
up after the incident occurs.
-

23. - Document on the OVR the actions
taken and/or any corrective measures,
taken to prevent the recurrence of the
event.
-
 Evaluates incident if meets sentinel event
criteria.


24. - Forward the completed (original)
OVR report form to the Total Quality
Management office within 72 hours
(3 days) of the occurrence.
-72

25. - Conduct any further investigation
and document, report investigated
findings upon request of the
Hospital Administration the Quality
Management Committee or the
Safety Committee.

26. 2. The employee who witnesses
or discovers
2
2.1 Immediate notification of
attending physician in case of
injury and Immediate
Supervisor

27. 3. Attending Physician
4
- Complete and document his/her
action(s) on the OVR form
immediately upon carrying out his
examination and/or the required
treatment or care.

28. 5. The Total Quality Management
Department is responsible for:
- Monitoring all OVR for follow up.
- Trending and preparing a
monthly summary.
:
-
-

29. - 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
:
-
-

30. 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
-
-

31. 6. The Safety Officer
- Document the results of
investigation and corrective action
taken on the OVR form and
forwards it to the TQM.
6
-

32. EQUIPMENTS AND FORMS
1. Occurrence
Variance Report
Form
1.

33. Sentinel Event
 An unexpected occurrence
involving death, serious physical
or psychological injury to the
patient


34. Reportable Cases
• An unanticipated
death
• Major permanent
loss of limb or
function, not
related to the
patient’s illness or
underlying
condition
• Infant abduction
.



35. Reportable Cases
 suicidal attempt
within the hospital
premises.
 Rape
 Physical assault of a
patient, staff or visitor
 Infant discharge to
the wrong family



.

36. Reportable Cases
• 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.)
•
•

37. Sentinel Event ReportingProcess
1. Immediate notification
1
 Departmental Quality Improvement
Designee/Coordinator
(QIC/Designee)


38. 2. The QIC/D will notify
2
 Head of the Department

39. 3. The QID/C will call or bleep
(223) Quality Improvement
Coordinator (Ms. Ellen Zamora)
by phone or in person.
223

40. 4. Occurrence
Report should be
submitted to the
Quality
Improvement
Coordinator
4

41. 5. Quality
Improvement
Coordinator will
conduct an
investigation
and interview
the involved
person and/or
any witness of
the event.


42. 6. Quality Improvement
Coordinator will notify
the Sentinel Event
Committee and
convene for a meeting.
6

43. 7. Root Cause Analysis will
be initiated and facilitated.
7

44. 8. Action plan will be designed
as appropriate and
implemented immediately.
8

45. 9. All investigation and conclusion
documentation will be in the custody
of the Total Quality Management
Department and remained
confidential.
9

46. 10. Follow up assessment will be
conducted by SEC and the concerned
department within six (6) months of
the event
10