2. Presentation Outline
What is Occurrence / Variance Report (OVR)
Near Miss
Basic Categories to include on an OVR
OVR sequences
Role of Quality Department related to OVR’s
3. Definition:
An incident that occurs in hospital property which is
out of the ordinary and/or deviates from standard
practice or behavior and affects the health & safety of
patient of patient/staff/visitors
4. Definition:
Near Miss:
An event or situation that could have resulted in an
adverse event but did not (occur) either by chance or
through timely intervention.
Example: Epinephrine was almost administered
instead of Lidocaine but uncovered during the final
check of the nurse.
5.
6. Sentinel Events:
Is defined as unexpected occurrences that involve
deaths or serious physical injury or psychological
injury or the risk event.
7. Basic Categories to Include on an OVR:
Medication and Intravenous errors
Reactions to medications or blood requiring
intervention
Falls
Surgical or Diagnostic error
10. Employee Injuries
Lost or retained operative material
Malfunctioning equipment or improper utilization of
equipment or improper utilization of equipment that
results in or has potential of resulting in patient
injury.
Wrong results affecting patient treatment
11. Delays in reporting highly critical results
Incorrect labeling of specimens
Loss or damage to property
Injuries to patient during treatment
Patient complaints
12. ALL INCIDENTS WHICH NEEDS TO BE REPORTED MUST
BE DOCUMENTED ON AN Occurrence/ Variance Report/
form
13. OVR must be:
Completed by the person finding the incident
Completed in full
The person reporting the OVR must inform the
department supervisor on duty in their area immediately
Any OVR of a serious nature must be reported to the
Duty Manager (out of hours) for the immediate action.
14. Forwarded to the Quality management/
Performance Improvement Manager within 24 hours
(48 hours if the OVR requires investigation by the
initiating department)
15. If requires investigating/forwarding to a department
other than the initiating department for follow up
this will be carried out by the PI Management
16. Any OVR given to your department for follow up
MUST be returned to the QM/PI Manager within 48
hours.
17. No photocopies of OVR are allowed as they are
classed as confidential documents for Risk
Management processes.
18.
19. Role of Quality Department
Receive the OVRs, must be within 24 hours from the
occurrence.
Investigate the incident whatever to whom/or and
with whom.
Correct the process if we need to correct, in
cooperation with concerned department.
20. Therefore….
It advised that each department have their own
logbook of OVR and follow up reports for future
reference if required.
21. A hospital operates on
the wrong side of the
patient’s body.
A death or loss of
function following a
discharge against
medical advice (DAMA)
Medication errors that do
not result in death or major
permanent loss of function.
Suicide other than in an
around-the-clock care
setting or following
elopement from such a
setting.
22. Minor degrees of hemolysis
not caused by a major
blood group
incompatibility.
A foreign body, such as a
sponge or forceps, that was
left in a patient after
surgery.
A patient commits suicide
within 72 hours of being
discharged from the hospital
setting that provides staffed
around-the-clock care.
Any intrapartum (related to
the birth process) maternal
death.
23. Any Sentinel event that has
not affected a recipient of
care (patient, individual,
resident)
A patient is abducted from
the hospital where he/she
receives care, treatment, or
services.
Hemolytic transfusion
reaction involving major
blood group
incompatibility.
Unsuccessful suicide
attempts unless resulting in
major permanent loss of
function.
