This document outlines an occurrence variance reporting system used by a hospital to systematically identify and address issues that pose safety risks. It defines key terms like occurrences, variances, sentinel events and provides guidelines for reporting, investigating and taking corrective action for different types of incidents. The goal is to use this non-punitive approach to monitor quality, ensure patient and staff safety, and implement improvements through confidential reporting and analysis of issues.

1. Dr. Mushtaq A. Khosa
29 January 2015

2.  To provide a systematic, standardized hospital-
wide mechanism to identify and/or to develop
prevention/improvement programs which have
direct or indirect adverse effect on patient care;
and which represent a potential hazard to
patients, visitors, volunteers, trainees, employees
or the facility as quality improvement approach.
OVR shall be used as a mechanism for monitoring,
Quality Improvement in a Non Punitive Approach.

3.  To establish clear systems for hospital-wide
reporting of information related to medical/health
care errors, and to provide a confidential
mechanism of identification, tracking, trending,
and follow-up
of all incidences that pose an actual or potential
safety risk to patients, families, visitors and staff.
Variances include events ranging from “falls "to
near misses or sentinel events with serious adverse
outcomes, occurring in the hospital setting.

4.  an internal form _____________ used to document
the details of the occurrence/event and the
investigation of an occurrence and the corrective
actions taken.

5. An event which is not consistent with routine
patient care or the routine operation of the facility
and which adversely affects or threatens the health
or life of the patient, visitor ,employee, student or
volunteer which involves loss or damage to
personal and/or hospital property.
An Occurrence is defined as any event or
circumstance that deviates from established
standards or care.

6.  It is essential that following any occurrence variance or
adverse event, an OVR is completed and forwarded to
Quality Management Department (QMD). The report is
checked for completeness, logged, forwarded to the
designated QM Coordinator, sent to the Concerned
Department where appropriate action is taken relating to
the event. On completion the OVR is returned to Quality
Management Department where the designated
coordinator will check the action and provide feedback as
required. It is then scanned, returned to the Reporter, and
any concerned persons/department heads. In some
instances an OVR may involve two departments and a
photocopy of the original OVR is made and sent to the
respective department for follow up.

7. If a particular OVR requires further investigation,
this is the responsibility of the concerned
Department. For example a policy may need to be
revised or developed, a procedure reviewed,
equipment changed, resources re-allocated.
If, on receiving an OVR it is classified as a Sentinel
Event it is raised to the Director of QMD who will
initiate appropriate action and/or decide on an
investigation using, for example, a Root Cause
Analysis approach.

8. It is an unwanted, undesirable and usually
unanticipated event such as death of a patient, an
employee or a visitor in a healthcare institute.

9. It is the difference in results obtained in
measuring the same phenomenon more than once

10. An event or situation that could have resulted as
an accident, injury or illness but did not either by
chance or through timely intervention .

12. A Sentinel Event is defined as an unexpected
occurrence involving the death or serious
physical or psychological injury, or risk thereof,
including loss of limb or function, signaling
the need for immediate investigation and
response.

13. Unexplained or unexpected deaths or permanent
loss or function of a limb that is not a result of the
patients medical condition.

14. 1. Surgery on the wrong patient
2. Surgery on wrong body part
3. Wrong surgical procedure.
4. Infant abduction
5. Child discharge to the wrong family
6. Hemolytic blood transfusion
7. Patient suicide in the Hospital
8. Rape/sexual harassment of a patient, staff or
visitor

15. 9. Retained Instrument or sponge
10. Intra vascular Gas embolism
11. Maternal Death
12. Medication error s leading to death or Major
morbidity.
13. Patient’s fall resulting in death or loss of
function of a body part.

16.  All sentinel events require immediate attention,
investigation and appropriate response by the
corresponding committees.
ALL EVENTS SHOULD GENERATE AN OVR.

17. 1. Identification of a sentinel event.
2. Appointment of a Task Force
3. Completion of root cause analysis
4. Committee Report.
5. All reports generated by committee or Task force
members are confidential and Privileged.

18.  It is the Responsibity 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.

19.  NURSES
 TECHNICIANS
 DOCTORS
 HEAD OF THE DEPARTMENTS
 QMD
 HOUSE KEEPING
SOCIAL WORKERS

20.  The employee who witnesses an occurrence has
the professional responsibility to immediately
notify:
a) The Physician on call if the occurrence
involves any question of patient and/or employee
injury or harm.
b)The Area supervisor to Generate an OVR.

21. Ensure that all the employees are aware of the
OVR system.
Conduct immediate follow of the occurrence.
Ensure thorough and accurate completion of the
OVR form.
Forward the completed OVR within 72 hrs to
QMD to initiate further process.

22. Investigate all safety related incidents.
Organize a review team of selected safety
committee to investigate critical safety related
occurrences.
Document the result of investigations and
corrective measures taken on the OVR form and
forward it to the TQM department.

23.  QMD is responsible for managing all OVR’s for follow
up ,Trending and preparing a monthly summary of all
Reported occurrences. The QMD will officially submit
the report to the head of the concerned department
for further course of action and make sure that all the
process shall remain confidential submitting a
quarterly report to the regional TQM maintaining a
record file of all OVR’s submitted. Identify steps ,hold
discussions on what actions can be taken to avoid
recurrence of an event.

24. 34.83%
32.52%
32.58%
1434-1436 OVR
1436 (MONTH 1-8)
1435
1434

25. 1434 OVR
Patient Misbehavior 8
Absconded 5
Needle Prick 4
Medical Record 3
Medication Error 3
Oxygen Flowmeter broken 3
Laboratory Services 2
Patient Identification 1
Laundry Services 1
Overstaying Patient 1
25%
15.62%
12.5%
9.37%
9.37%
9.37%
6.25%
3.12%
3.12%
3.12%
1434 OVR
Patient Misbehavior
Absconded
Needle Prick
Medical Record
Medication Error
Oxygen Flowmeter broken
Laboratory Services
Patient Identification
Laundry Services
Overstaying Patient

26. 24.13%
13.79%
13.79%
10.34%
10.34%
6.89%
3.44%
3.44%
3.44%
3.44%
3.44%
3.44%
1435 OVR
Absconded
Security Problem
Misbehavior of staff
Needle Prick
Resident refuse to see pt. in DR
Patient Identification
No staff in reception
Suspected MERS-COV not
endorsed
Laboratory Services
Maintenance for Equipment
Bladder Injury
Refusal to Accept patient
1435 OVR
Absconded 7
Security Problem 4
Misbehavior of staff 4
Needle Prick 3
Resident refuse to see pt. in DR 3
Patient Identification 2
No staff in reception 1
Suspected MERS-COV not endorsed 1
Laboratory Services 1
Maintenance for Equipment 1
Bladder Injury 1
Refusal to Accept patient 1

27. 27.58%
24.13%
13.79%
13.79%
6.89%
3.44%
3.44%
3.44%
3.44%
1436 OVR
Month 1-8
Needle Prick
Violent Patient
Laboratory Services
Absconded
Misbehavior of employee
Medication error
Refused to answer phone during
on-call
Patient Identification
Referring patients without doctor
1436 OVR
(Month 1-8)
Needle Prick 8
Violent Patient 7
Laboratory Services 4
Absconded 4
Misbehavior of employee 2
Medication error 1
Refused to answer phone during on-call 1
Patient Identification 1
Referring patients without doctor 1

31. • Miscommunication
• Accidental needle prick
• Absconding staff/patient
• Undocumented /wrong blood extraction
• Problems in cleanliness
• Prescribed medicines not transcribed
• No response to call involving consultants ,staff, security and others .
• Violations in standard precautions
• Delays
• Non availability of supplies /forms
• Expired blood or Medications
• Wrong patient Identification.
• Others (specify)
REPORT THE DETAILS OF ANY OCCURANCE WHICH HAS AN
ADVERSE IMPACT ON PATIENT CARE.

32. The Occurrence report shall not be placed in the
medical record (Patient File) nor in Employee
OVR should not be duplicated with exception
of the TQM department.
The information contained in the OVR form
cannot and will not be used against any
individual as basis for any disciplinary action
File.

33.  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.
Discussion of general issues on OVR for
instructional or education purposes with view
to improving patient care is, however
strongly encouraged.

34.  The aim of the study was to improve Occurrence
Variance Reporting System
Occurrence variance reporting (OVR) is very essential
for ensuring patient and staff safety, quality of care and
risk management.
Steps to identify, report, and follow up an adverse
event include identifying an adverse event, report the
adverse event, explore the cause of the event through
root cause analysis, and use the result of the analysis to
make improvement

35. THANK YOU