Transcript Veritas for the Operating Room

Veritas-Reporting for the
Operating Room
Purpose
To assist the staff in choosing the correct
Event categories and Nature of event
categories in order to have consistency
through out all the Operating Rooms
To provide accurate data from the event
reports to manage and improve our patient
care
2
The Beginning
To enter an Event Report:
Clinical Workstation, click on Veritas Icon
Administrative Workstations ,click on VUMC
home page, go to Eskind Digital Library,
Choose “ V “, scroll down to Veritas RM and
click. Log in “no feed back”.Use your
VUNetId.
When you get to Event Category ,choose
the one that fits your situation
3
4
Event Categories
Patient: any event involving
inpatients,outpatients, or clinical
issues
Visitor/Physician/Other:
any event involving visitors,family
members, students, contract
employees,or non-faculty
physicians.
Property/Equipment/
Narcotic Counts: no
association with a patient
5
Nature of Event
It is in this Category that the person submitting
the Report has a number of choices to make.
Choices must be consistent. The following is an
explanation of the categories with O.R.specific
impact
Categories that are non-OR related [High forceps
deliveries] or that are self explanatory[Falls] or
that apply to the OR the same as to the rest of the
units[Cardiac/Respiratory arrest] will not be
discussed here.
6
Admission Unanticipated
Admission Unanticipated:
• Any unscheduled or unplanned admission
following any ambulatory or out patient
procedure
Transfer – Unanticipated Intra Hospital
• Sudden, unexpected change in patient condition
requiring a change in unit I.e. to SICU etc
7
AMA/Elopement/LWBS
Against Medical Advice{AMA} - patient leaves
the hospital against the advice of the physician
Elopement - patient chooses to leave the hospital
without the knowledge of the physician or any
other staff.
Left Without Being Seen{LWBS}- patient
completes a registration process then leaves the
hospital and is not treated
8
Accidental Skin Injury
Any injury to the patient which could be the
result of a medical procedure or other
facility related injury, such as:
Red pressure areas due to positioning
Betadine burns,rashes
Towel clip injury
Lacerations, scratches apparent upon removal
of drapes that did not exist preoperatively
9
Anesthesia Related Event
Unexpected patient outcome or complication
following anesthesia
Tooth damage
Skin damage from taped ET Tube
DOES NOT include infiltrated IVs or any other
IV issue
Anesthesia Recall the patient remembers the
surgery
10
Blood Administration / IV
Access Related
An event related to the administration of IV
solutions or blood products
•
•
•
•
•
•
•
•
Transfusion reactions
Infiltration, contaminations
Phlebitis
Delays in administration
Wastage
Wrong Blood
Clotted port
Access cap issues
11
Blood and Body Fluid Exposure
Non Employees only
All OR staff, Attendings, Residents,
Students on rotations from schools with
which we have a contractural relationship
will need to use Tennessee First Report of
Work Injury Form.
Needle sticks are handled as above
12
Conduct/ Behavior/Altercation
Patient, Staff, Physician, Visitor displays a
negative change in behavior during the
course of direct or indirect care or service
13
Consent Form Related
Variances to be reported:
No consent
Incomplete consent
Consent and procedure do not match
Patient revokes consent, chooses not to have
surgery
14
Delay in Response Time
Significant disruption in care or a delay in
response by individual/department other
than Perioperative Services (Does not
include lab test results)
All Perioperative Services delays will be
captured using the Delay tab in VPIMS
15
Diagnosis-Related
Incorrect, incomplete or delayed diagnosis
which may or may not affect change in
treatment.
Missed fracture
Negative frozen section –positive for cancer on
permanent slide
Cholelithiasis instead of appendicitis
16
DOA/Death Unanticipated
All interoperative deaths .
Do not use for Organ Harvests
17
Dissatisfaction
Non – Patient Related
Visitor,Physician or other non patient expresses
dissatisfaction with an adverse outcome,
increased risk potential, or the potential for a
catastrophic outcome.
Patient Related
Same as above
18
Three Equipment Choices
Equipment Related: use for non-medical
equipment malfunction
Furniture, vacuum cleaners, lamps
Malfunction of Medical Device Disposable,
Single use:
Drains, Internal Staplers
Malfunction of Medical Device Reusable:
Instruments, power equipment, Bovie, Laser
19
Health Care Related Infection
Nosocomial or not present on admission
Not related to underlying disease or
diagnosis
Postop wound infection following a Class1
“clean” case. This is a new category to
report
20
Intubation Related
Involves any issues relating to the ETT
Repositioning
Accidental extubation
Change in condition after planned extubation
Airway issues during a tube change
Emergent reintubation
21
Medication-Adverse Reaction
Patient has unexplained, new, or serious reaction
to a drug.
An adverse reaction is unrelated to the drugs
pharmacological effects that occurs at normal
doses indicated by manufacturer.
Class 1 [ mild] rash, hives, nausea, vomiting
Class 2 [ moderate] Requires therapeutic
intervention/prolonged hospitalization
Class 3 [severe] threatens life, permanent disability,
coma
Class 4 [death] results in death
22
Medication Issues
There are two main categories
• Medication –Adverse Reaction
• Medication –everything else





Administration
Dispensing
Prescribing
Monitoring
Order entry
These are self explanatory
23
Patient Identification
An event that includesNo ID band
Incorrect ID band
Two patient identifiers do not match
24
Procedure/Treatment /Test
An event related to procedures, treatments, tests,
and processes
•
•
•
•
•
•
•
•
Specimens,lost, mislabeled
Test results delay
Contaminations,breaks in technique
Interdepartmental issues –Lab,Central Sterile, Steril-Tek,
Blood Bank, Patient units
Instrument issues
Bed issues
Case boarding issues
Room Issues- Lights, bugs
25
Special Note
Procedure, Treatment, Test is a big category
for the OR
Choose this category when no individual
category exists
Example: no id band or no consent. Both are
procedure related but they each have a category
of their own.
In this event, use the specific category, not the
general one.
26
Removal/Repair Organ/Body Part
Unplanned removal or repair of an organ or
body part
Nicked organs, blood vessels requiring
additional surgery
Nicked organs or blood vessels resulting in
patient injury
27
Sponge /Needle/ Instrument Count
An event involving omissions and variances
in counts.
Event reports are filed on all of these, even
the frequent “bring backs”
There is a place for choosing the type of
incorrect count
28
Type of incorrect count
The choices are:
•
•
•
•
•
Instrument
Needle
Sponge
Incorrect count-closed wounds
Incorrect count- packed wounds
Using the “ packed wound” choice is where
all the trauma wounds that we bring back
for debridement needs to be documented .
29
New Occurrences
The following categories are new events
requiring reports
Return to surgery within 48 hours
Transfer –Unanticipated - Intra-hospital
Transfer – Unanticipated –Outside facility
30
Wrong Site/ Wrong Procedure
Misidentification of surgical site
Incorrect procedure performed
A “near miss” should also be entered
31
Near Misses
Facilitates evaluation and identification of
causes[s] to prevent an event from actually
happening:
Improperly stored equipment/medication
Wrong patient identification
Wrong site/side identification
Laps /raytecs found on x-ray before wound
closed or patient out of room
32
Near Misses/ Medications
To enter a medication near miss click the
medicine bottle on the log in screen instead
of clicking on the “Login’ button
33
Finally
This information plus all the categories not
discussed is located in the handy reference
material mounted on the left side of your
computer screen.
34