To establish and outline procedures for reporting any unusual event that occurs in or on the premises of OUR HOSPITAL - Occurrence reports serve to analyze the frequency and causes of general and specific types of events. This data is used to identify opportunities for improvement.
An occurrence/incident is any unusual or unexpected, recognized, suspected, or potential event or condition that is not consistent with the routine safe delivery of patient care or operations of OUR HOSPITAL. Such unusual or unexpected events may include, but are not limited to:
- All personnel injuries regardless of severity to patients, visitors, volunteers, vendors, or students to be reported on the Occurrence Report - Injuries to staff are to be reported on the Employee Occurrence Report. Employee Occurrence Reports are maintained by the Employee Health Department.
- All damages to or loss of personal/hospital property
- Variations from established policies and procedures regardless of whether personal injury or property loss is involved - Policy and procedure variation can be related to medication dispensing and administration, diagnostic and therapeutic procedures, interruption of a support service (heating/cooling, food service, linen, etc.).
- Any unexpected clinical complication, regardless of whether a policy or procedure variance is involved, that may result in additional care or observation or prolonged care or surgery
- Any potential safety hazard that may be related to medical devices and / or products or a release of a hazardous material should be reported. Additionally, immediate notification to the responsible department is necessary.
- Reporting of occurrences related to the Safe Medical Devices Act, reportable events, anesthesia licensing standards, will be done by the person witnessing the occurrence. During non routine business hours, contact the administrator on-call.
Occurrences Reportable To Quality Council
- Any event where information suggests the probability that a medical device has caused or contributed to the death, serious injury, or serious illness of a patient, requires reporting to the manufacturer.
Medical devices include, but are not limited to, ventilators, monitors, electronic equipment, implants, in-vitro diagnostic test kits and reagents, disposable components, parts accessories, software, and user error caused by device design or labeling.
Serious injury and serious illness are defined as:
- Life-threatening, permanent impairment of a body function or permanent damage to a body structure.
- Necessitating medical and surgical intervention to preclude permanent impairment of a body function or permanent damage to a body structure.
- Any event that jeopardizes the health and safety of patients or employees requires
immediate reporting - Events include but are not limited to:
- An unscheduled interruption for 3 or more hours of physical plant and/or clinical services essential to the health and safety of patients and employees
- All fire disasters, or accidents that result in serious injury or death of patients or employees or in evaluation of patients out of the facility
- All alleged or suspected crimes which endanger the life or safety of patients or employees that are also reportable to the police department and that result in an immediate investigation by the police
- All deaths in anesthetizing locations and unexpected intra-operative or post-operative events or outcomes related to anesthesia require reporting to the division of health facilities evaluation within 24 hours.
- Reporting - All staff are required to complete an occurrence report form whenever they believe the definition of an occurrence is met. The rule of thumb is: "When in doubt, fill it out." There is no consequence for an occurrence that does not meet the definition. It is important to note that occurrence reports are not to be used to document opinions or judgments concerning the potential causes of or solutions to occurrences. Document only the facts. Staff is encouraged to verbally communicate any such opinions or judgments to the risk manager.
- Who should complete an occurrence report? - The staff member (employee, nursing/medical student, attending physician, etc.) who is most closely involved with and/or witnessed the occurrence should complete a report. Patients and visitors should never complete an occurrence report. Occurrence reports are to be reviewed and countersigned by the supervisor of the unit/department where the occurrence occurred.
- Timetable/Routing - Occurrence report forms are to be completed prior to the close of shift on the day of the occurrence. It is important that reporting occur while details are fresh in one's mind. Upon completion, completed occurrence reports are to be forwarded within 24 hours to the risk manager.
Note: Occurrences that involve significant risk or require prompt intervention are to be called to the attention of the risk manager immediately. During non routine business hours, the administrator on-call must be contacted. The written occurrence report will be completed as stipulated in this policy.
- Confidentiality - The occurrence report is considered a confidential document and should be treated as such. With regard to patient-related occurrences, the occurrence report itself is not to become a part of the patient's permanent medical record. It should not be shown, copied, or discussed with a patient, family member, or anyone else not directly related with the completion or review of the report.
- Supplies and forms - Each nursing unit and department is responsible for maintaining an adequate supply of occurrence report forms. These forms may be obtained from the quality office or safety office.
Occurrences Involving Patients
A staff member having first knowledge of an occurrence is to:
- Secure medical treatment for the patient if it is immediately apparent that attention is warranted.
- Immediately fill out an occurrence report - Locate the heading that best applies to the occurrence and complete all applicable sections.
- The supervisor on duty will contact the attending physician, if appropriate.
- Document the occurrence in the patient's medical record if his/her condition or care is affected.
It is not necessary to document in a patient's medical record that an occurrence report has been filed; only note the circumstances of the occurrence.
The signed occurrence report should be forwarded to the risk manager within 24 hours of the occurrence.
Staff members must complete the occurrence report form immediately. Seek assistance for completion from department heads or supervisors if necessary. Upon completion of the report, forward it to the supervisor on duty. The supervisor on duty will review and sign the occurrence report within the shift of occurrence.
- Department heads will investigate the occurrence and assure appropriate corrective action is taken.
- Occurrence report forms and all supporting documentation should be forwarded to employee health immediately.
Visitor/Volunteer Occurrences Reporting Party:
- Immediately fill out an occurrence report.
- If the individual is not injured or refuses medical treatment, forward the completed occurrence. Report to the department head where the occurrence took place.
Note: If the individual refuses medical treatment, this must be documented on the occurrence report.
Emergency Department Physician:
- Promptly examine the patient and provide necessary care.
- Review, report, and provide additional information as necessary.
- The occurrence report should never become a permanent part of the medical record.
- Review occurrence report.
- Sign the completed report.
- Forward completed report to risk manager within 24 hours of the occurrence.
Employee Occupational Injury/Illness Reporting
Any individual employed by OUR HOSPITAL or student
- An employee who sustains an injury or illness, no matter how minor, should immediately notify their supervisor. Occurrence report forms are to be completed prior to the close of the shift on the day of the occurrence. It is important that reporting occur while details are fresh in one's mind.
- The individual, with the assistance of their supervisor, must immediately complete an occurrence report. The report must be countersigned by a supervisor present in the area where the occurrence took place.
- The employee must be seen for initial treatment in the emergency room or by employee health.
- If the injury requires emergency treatment, the employee should go directly to the emergency room.
Emergency Room Reporting of Employee Occupational Injury or Illness
- Following evaluation, the employee should be instructed to contact employee health to take over treatment and/or provide referral.
- The Emergency Department must immediately forward all pertinent medical records and the completed occurrence report to employee health.