Transcript No Slide Title

Incident Reporting
2009 employee education competency module
DMC Corporate Quality Department
Detroit Medical Center©
Revised: December, 2008
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Medical Safety Reporting
• It is the policy of the DMC to report all
incidents, accidents, or occurrences that
cause or could potentially cause injury or
harm to an employee, patient or visitor in the
DMC:
• See DMC policy 1 CLN 026 Incident
Reporting for additional information
or clarification
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Medical Safety Reporting
• Most events or errors occur due to process issues:
 Multiple events at multiple levels lead to the event – almost
never just one process failure
 Rarely a “person” failure
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Medical Safety Reporting
The DMC supports a blame-free environment:
• All employees are encouraged and urged to report all
events and occurrences
• By reporting all events that occur, we can investigate and
get to the root cause of the error
• By getting to the root cause of an error, we can fix the
underlying system or process issues
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Medical Safety Reporting
 What to report:
 Error - An unintended act, either of omission or commission.
 Near Miss - Used to describe any process variation which did not
affect the outcome, but for which a recurrence carries a significant
chance of a serious adverse outcome.
 Hazardous Condition - Any set of circumstances (exclusive of the
disease or condition for which the patient is being treated), which
significantly increases the likelihood of a serious adverse outcome.
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Incident Reporting: Types of Incidents
Adverse Drug Event:
• Adverse Drug Reaction: Unexpected, unintended,
undesired or excessive response to a medication.
• Medication Variance: Any preventable event that
may cause or lead to inappropriate medication
use or patient harm while the medication is in the
control of the health care professional, patient or
consumer.
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Types of Incidents: - continued
Patient Incident:
• Any patient related incidents, including lost or damaged
patient belongings.
Employee Incident:
• Any employee incident, including workplace conflict.
Visitor Incident:
• Any incident that involves or affects a visitor.
Property Incident:
• Lost or damaged property belonging to visitors or
employees of the DMC.
These type of incidents are reported directly to Security.
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Patient Incidents:
• Patient Incidents are any events that involves the patient
including but not limited to:
- Patient injury including falls and hospital acquired pressure
ulcers or infection.
- Missed, delayed or wrong treatment or procedure.
- Medication events that involved a patient.
- Breach of patient confidentiality (HIPPA violations).
• It is also necessary to document patient incidents in the
medical record.
- An objective note should be placed in the patient’s medical
record documenting the facts and events of the occurrence,
physician findings and treatment.
• DO NOT document that an incident report has been filed or
refer to the incident #.
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Patient Incidents Involving Medical Devices:
Medical Device Incidents:
• Incidents in which a medical device may have caused a
patient’s death, serious illness or injury or has information
critical to the investigation.
• A medical device may be a piece of equipment (IV
pump, cardiac monitor or a patient care item (such as
foley catheter).
• Remove device from service, tag it and report incident
immediately.
• See 1CLN 017 Safe Medical Device Act.
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Patient Incidents Involving Medical Devices con’t:
 Keep device/equipment on unit.
 If device was electrical and plugged in – DO NOT
unplug
 Notify Risk/Quality/Biomed immediately
 Biomed must be notified if telemetry device was
involved and must retrieve data from device as
soon as possible.
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Medical Safety Reporting
Definitions:



Unexpected Clinical Event: any clinical event that is not an expected part of
the patient’s care or condition, which occurs in the hospital that may or may
not have been preventable and may or may not have resulted in harm.
Reviewable Event: is an unexpected occurrence involving death or serious
physical or psychological injury, or the risk thereof. Serious injury
specifically includes loss of limb or function. The phrase “or the risk thereof”
includes any process variation for which a recurrence would carry a
significant chance of a serious adverse outcome. Such events signal the
need for immediate investigation and response (also referred to as “Sentinel
Events” by the Joint Commission).
Serious reportable event: Events that are of concern to both the public and
healthcare professionals and providers, clearly identifiable and measurable;
and of a nature such that the risk of occurrence is significantly influenced by
the policies and procedures of the healthcare organization (also referred to
as “never events”).
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Unexpected Clinical Events
An Unexpected Clinical Event is an unanticipated death or major
permanent loss of function not related to the natural course of the
patient's illness or underlying condition. All reviewable events and
serious reportable events are unexpected clinical events.
 Unexpected clinical events need to be reported immediately
to the department manager and also entered into the webbase reporting system.
 The manager will then immediately notify risk management
and the Chief Medical Safety Officer.
• See 1 CLN 027 Unexpected Clinical Events
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Reviewable Events (“Sentinel Events”) and
Serious Reportable Events (“Never Events”):
 In the event of any Joint Commission defined sentinel, any NQF
serious reportable event (“never event”) or other significant events,
the following needs to occur at the site:
 Site quality will notify corporate quality (a phone call to CQSO; if
away then the director of quality) and hospital leadership.
 Start local investigation. If this is a reportable event,
investigation must be complete within 10 days.
 Circle back to attending physician to ensure that communication
with patient/family has occurred.
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Reviewable Events (“Sentinel Events”)

As defined by the Joint Commission, reviewable events include:
 Suicide, Homicide, Rape or Elopement
 Infant discharge to the wrong family.
 Abduction of any individual receiving care, treatment or services.
 Hemolytic transfusion reaction involving administration of blood or
blood products having major blood group incompatibilities.
 Surgery on the wrong patient or wrong body part.
 Unintended retention of a foreign object in an individual after surgery or
other procedure.
 Death or major permanent loss of function as a direct result of a
healthcare associated infection, medication error, or patient fall.
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National Quality Forum’s (NQF)
Serious Reportable Events (“Never Events”)



Some examples of Serious Reportable Events:
 All the JC Reviewable Events
 Patient death or serious disability associated with intravascular air
embolism that occurs while being cared for in a healthcare facility
 Patient death or serious disability associated with hypoglycemia, the
onset of which occurs while the patient is being cared for in a health
care facility
 Stage 3 or 4 pressure ulcers acquired after admission to a healthcare
facility
There are 28 NQF Serious Reportable Events. They are reviewed and
updated annually.
If a serious reportable event (never event) occurs, the DMC CQSO will
notify Patient Finance Services who will waive all charges directly related to
the event and refrain from seeking reimbursement from the patient or third
party payor.
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Employee Incidents:
• Employee Incident is any event occurring in the DMC or on
the premises to an employee that is not consistent with the
employee’s routine work, and may adversely affect or
threaten to affect the health, life, comfort, or property of an
employee.
• Occurrences to be reported include (but are not limited to):
- Slip, trips and falls.
- Needle/sharps injuries and splashes of blood or body
fluids to the eyes, nose, mouth or non-intact skin.
- Other incidents that result or may result in injuries to
employees, including potential Workers’ Disability claims
and incidents which require MIOSHA filing.
- Incidents of workplace conflict and/or verbal, physical, or
emotional abuse or harassment - see 1 HR 507 Prevention
of Workplace Violence.
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Reporting Employee Incidents:
• All employee incidents are reported to the
department manager and entered into the web
based incident reporting system.
• The Employee Injury/Illness Report is also
completed per MIOSHA regulations.
• The employee is to report to the Emergency
Department or Occupational Health as per site
protocol.
• The employee takes the Employee Injury/Illness
Report with them when they report for evaluation or
treatment to the ED or OHS.
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When Should You Report An Incident?
• As soon as it happens or as soon as you find out
about it.
- See 1 CLN 026 Incident Reporting Policy.
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How To Report An Incident:
The DMC uses a web-based incident reporting system that
allows our organizations to report, track, and prevent medical
errors and near misses.
•All Detroit Medical Center employees can access the web
based reporting system for the purpose of incident, near
miss reporting and complaint reporting.
•Web-base incident reporting can be accessed using the
desktop icon or through the Intraweb (select “Incident
reporting” under the Quality and Safety tab) on any PC
workstation with Internet access.
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Incident Reporting:
To access web-based incident reporting:
• Select the incident reporting icon (or tab on intraweb home
page),
• Select SRM 5.0 then select Patient, Employee, or Visitor to report
an event,
If you are unable to access the web-based incident reporting system using
the internet for any reason, a paper form will be available.
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Incident Reporting – Staff Responsibilities:
• Staff will enter any patient, visitor, employee,
medication or workplace conflict related incidents
or near misses into web-based incident reporting
system or report the incident to a supervisor for
entry into the web-based incident reporting system.
• Staff will report any work-related accident, injury,
or near miss to their supervisor or department
manager immediately following the occurrence .
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Incident Reporting – Management Responsibilities:
• If paper form was used to report the incident, department
manager or designee will enter information into the web-based
incident reporting system and destroy paper form after entry.
• Managers or their designees review incidents involving their
respective areas.
• Investigate incident, interview employee(s) and if appropriate,
determine additional factual information. Add any missing
information regarding circumstances. Review level of impact
and adjust as appropriate. Refer reports to other involved
departments as indicated.
- Complete entry of the data components, including follow-up
investigation and corrective actions.
- Events are to be reviewed and have documented follow-up within 7
days of event entry.
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Incident Reporting – Management Responsibilities: - cont.
• Department Manager, Site Administrator, Risk Management and
Quality Department are notified of any situation which may have
the potential for significant negative outcomes, serious patient
injury or adverse media attention. In these situations, refer to
the Unexpected Clinical Event policy 1 CLN 027 for further
information or direction.
• Notify the Safety Officer to report unsafe conditions or hazards.
• Report any employee lost time to Human Resources/Regional
Workers’ Compensation Administration within 24 hours of
incident.
• Identify, implement, educate and document actions taken to
lessen likelihood of incident recurring.
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Incident Reporting – Other Department Responsibilities:
• Pharmacy:
- Pharmacy reviews and closes all medication related
events.
- If a drug is reported to the FDA Medical Products
Reporting Program (MEDWATCH), pharmacy will
document this in the “follow up” section of the
incident report.
• Clinical/Quality Improvement:
- Clinical/Quality improvement reviews incidents.
- Clinical/Quality improvement closes all events with
level of impact category F or higher.
•If event is referred to peer review, or RCA/IA is being
conducted, document statement in follow up section.
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Patient, Family and Visitor Complaints:
The DMC encourages patients, families and visitors
to freely express their grievances, complaints,
concerns, dissatisfactions and inquiries through
established channels without being subject to
coercion, discrimination, reprisal, or unreasonable
interruption of care, treatment, and services.
Definitions:
Medical Grievance: Any complaint (written or verbal)
that involves treatment or care of the patient, including
complaints against physicians.
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Patient, Family and Visitor Complaints:
Complaint: Any expression of dissatisfaction related to an
occurrence that it is not able to be resolved to the satisfaction of
the patient/family at a departmental level and/or crosses multiple
service lines or departments (some examples include billing
issues, delay in service, or environmental concerns).
Concern/Dissatisfaction: Any expression of concern or
dissatisfaction that is resolved to the satisfaction of the
patient/family at the departmental level (some examples include
food temperature, TV or phone problems).
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Complaint Management:
• When a grievance, complaint or concern is received,
IMMEDIATE resolution at the department level is
attempted.
• If the complaint is not immediately resolved, contact
the appropriate management staff for intervention,
and enter the complaint into the DMC web-based
Incident and Complaint reporting system.
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Complaint Reporting:
 To access web-based incident reporting:
• Select the incident reporting icon (or tab on
intraweb home page),
• Select Feedback to report a complaint
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Complaint Management: - continued
The Patient & Guest Relations Representative or
other facility designee, will review all complaints
and determine if it will be classified as a Medical
Grievance, Complaint or Concern/dissatisfaction
and offer assistance and intervention in bringing
the matter to closure:
•See policy 1 CLN 033 Patient and Family Grievances and
Complaints
•The Patient & Guest Relations Manager closes all complaints
entered into the web-based incident reporting system.
Complaint management outcomes data is used to
identify opportunities for improving patient/family
services throughout the Detroit Medical Center.
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Compliance Hotline:
1-800-8ETHICS
•May report non-environmental issues such as harassment.
• Calls can be placed by patients, visitors or employees.
• Reporting may be done anonymously.
• Means to immediately report hazardous conditions and
other environment of care issues (examples – icy
walkways, elevator problems).
- You may also call your site Safety Officer
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Quality of Care
 As employees of the DMC, it is everyone’s responsibility to ensure
safe, quality care for our patients.
 Also, as an employee, you have the right and duty to speak up if you
feel the quality of care or patient/employee safety is compromised.
 If you have concerns, first speak to your supervision. If you are not
satisfied, you may contact the Quality Department or use the
compliance hotline.
 If still you concerns are not addressed, you have the right to Joint
Commission at www.jointcommission.org/GeneralPublic/Complaint,
E-Mail:[email protected],Fax:Office of Quality Monitoring
(630) 792-5636
.
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Summary
Types of incidents to be reported include patient, employee, visitor and
property.
The DMC supports a blame free environment and employees are encouraged
and urged to report all events and occurrences.
Incidents should be reported as soon as they occur or are known.
If a medical device is involved in the incident, remove device from service, tag
it and report incident immediately.
Incidents and near miss events are reported and entered into the web-based
incident reporting system.
Immediate action is taken to address/resolve any patient, family or visitor
complaint.
Anonymous reporting using the Compliance hotline may be used to report
non-environmental issues such as harassment.
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