OVR &

OVR &

SENTINEL

SENTINEL

EVENTS

EVENTS

TQM Department L

ecture

By

Dr. Aqeel A

hmed Khan

TQM Coordinator-ACH

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CONTENTS:CONTENTS:Definitions of termsDefinitions of terms• OCCOURANCEOCCOURANCE• OVROVR• ADVERSE EVENTADVERSE EVENT• VARIENCEVARIENCE• NEAR MISS (& why it should be NEAR MISS (& why it should be

reported)reported)• SENTINEL EVENTS SENTINEL EVENTS • “ “ “ “ (Types)(Types)• “ “ “ “ (policy)(policy)

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CONTENTS:CONTENTS:• SENTINEL EVENTS (Procedure) SENTINEL EVENTS (Procedure) • How to deal with sentinel/adverse How to deal with sentinel/adverse

eventevent• Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR• Who should report /responsibilitiesWho should report /responsibilities (Employee, attending physician, immediate (Employee, attending physician, immediate

supervisor, TQM department, safety officer)supervisor, TQM department, safety officer)• OVR policyOVR policy• OVR form restrictions OVR form restrictions • OVR form sampleOVR form sample• SummarySummary

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OCCURRENCEOCCURRENCE • An event which is not consistent with routine An event which is not consistent with routine

patient care or with the routine operation of patient care or with the routine operation of the facility & which adversely affects or the facility & which adversely affects or threatens the health or life of patient, visitor, threatens the health or life of patient, visitor, employee, student or volunteer which employee, student or volunteer which involves loss or damage to personal or involves loss or damage to personal or hospital property. An occurrence also hospital property. An occurrence also includes any event that might other wise includes any event that might other wise result in any other adverse situation or a result in any other adverse situation or a claim against the organization.claim against the organization.

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OCCURRENCEOCCURRENCE VARIANCE REPORT VARIANCE REPORT (OVR) DEFINITION:(OVR) DEFINITION:

• An internal form which is issued to An internal form which is issued to document the details of the document the details of the occurrence / event and the occurrence / event and the investigation of an occurrence and investigation of an occurrence and the corrective actions taken.the corrective actions taken.

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ADVERSE EVENTADVERSE EVENT• It is an unwanted, undesirable and It is an unwanted, undesirable and

usually unanticipated event such as usually unanticipated event such as death of patient, an employee, or a death of patient, an employee, or a visitor in a health care organization. visitor in a health care organization. Occurrences such as patient falls are Occurrences such as patient falls are also considered adverse events if also considered adverse events if there is no permanent effect on the there is no permanent effect on the patient. patient.

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VARIANCEVARIANCE• Is the difference in results obtained Is the difference in results obtained

in measuring the same in measuring the same phenomenon more than once. phenomenon more than once. Excessive variation frequently leads Excessive variation frequently leads to waste and loss; such as the to waste and loss; such as the occurrence of undesirable patient occurrence of undesirable patient health outcomes and increased cost health outcomes and increased cost of health services.of health services.

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

NEAR MISSNEAR MISS

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Why should report Why should report NEAR MISSNEAR MISS

Sentinel events

Adverse events

Near misses, other accidents and occurrences

• They have They have the same the same root causes, root causes, as sentinel as sentinel events, so events, so they should they should also be also be reportedreported

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SENTINEL EVENTSENTINEL EVENT(DEFINITION)(DEFINITION)

• Any unexpected occurrence Any unexpected occurrence involving death, serious physical or involving death, serious physical or psychological injury or the risk psychological injury or the risk thereof, and any event that might thereof, and any event that might cause embarrassment or risk to the cause embarrassment or risk to the hospital with potential legal hospital with potential legal implications and / or media inquires implications and / or media inquires or coverage.or coverage.

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SENTINEL EVENTSENTINEL EVENT• The phrase “or the risk thereof” The phrase “or the risk thereof”

includes any process variation for includes any process variation for which a recurrence would carry a which a recurrence would carry a significant chance of a serious significant chance of a serious adverse outcome. Such events are adverse outcome. Such events are called “sentinel” because they signal called “sentinel” because they signal the need for immediate the need for immediate investigation and response.investigation and response.

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SENTINEL EVENTSENTINEL EVENT(TYPES)(TYPES)

• Serious injury includes but is not Serious injury includes but is not limited to:limited to:

–Unexplained or unexpected deaths Unexplained or unexpected deaths or permanent loss of limb or function or permanent loss of limb or function that is not a result of the patient’s that is not a result of the patient’s medical condition.medical condition.

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– Surgery on the Surgery on the wrong patient wrong patient

– Surgery on wrong Surgery on wrong body partsbody parts

–Wrong procedure Wrong procedure Surgery Surgery

SENTINEL EVENTSENTINEL EVENT(TYPES)(TYPES)

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SENTINEL EVENTSENTINEL EVENT

– Rape of a patient, staff or visitorRape of a patient, staff or visitor– Infant abductionInfant abduction–Unexpected death of full-term infantUnexpected death of full-term infant– Child discharge to the wrong familyChild discharge to the wrong family–Hemolytic blood transfusionHemolytic blood transfusion– Patient suicide in the hospitalPatient suicide in the hospital

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– Retained instrument or spongeRetained instrument or sponge– Intravascular gas embolismIntravascular gas embolism–Maternal deathMaternal death–Medication Errors leading to death or Medication Errors leading to death or

major morbiditymajor morbidity– Patient’s fall resulting death or severe Patient’s fall resulting death or severe

dysfunction of body partdysfunction of body part

SENTINEL EVENTSENTINEL EVENT

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SENTINEL EVENT SENTINEL EVENT POLICYPOLICY

–All sentinel events require All sentinel events require immediate investigation and immediate investigation and appropriate response by the appropriate response by the corresponding committees. All corresponding committees. All events should have an occurrence events should have an occurrence generated report (OVR)generated report (OVR)

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SENTINEL EVENT SENTINEL EVENT PROCEDUREPROCEDURE

1.1. Identification of a Sentinel EventIdentification of a Sentinel Event2.2. Appointment of Task ForceAppointment of Task Force3.3. Completion of Root Cause AnalysisCompletion of Root Cause Analysis4.4. Committee ReportCommittee Report5.5. Any report or documents generated Any report or documents generated

by the Task Force are Confidential by the Task Force are Confidential and Privilegedand Privileged

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SENTINEL EVENT

Immediate Containment Action

Reporting and Notification

Investigation and Review

Action Plan & Monitoring

How to deal with a Sentinel How to deal with a Sentinel Event/Adverse EventEvent/Adverse Event

Unit heads /

dept chairsAP, Unit

heads / dept chairs +

Customer Service Unit heads / dept

chairs, AP, Team + Risk

Management Office

Unit heads / dept chairs, SQD + MQIO

Persons accountable

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PURPOSE OF OVRPURPOSE OF OVR• To provide a systematic hospital – To provide a systematic hospital –

wide identification mechanism as wide identification mechanism as quality improvement tool for early quality improvement tool for early detection and prevention of detection and prevention of problems which have (or may have) problems which have (or may have) an adverse patient outcome and an adverse patient outcome and represent a potential hazard to represent a potential hazard to patients, visitors, volunteers, patients, visitors, volunteers, students or employees.students or employees.

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PURPOSE OF OVRPURPOSE OF OVR• To plan and implement corrective To plan and implement corrective

measures through identification by measures through identification by root cause analysis.root cause analysis.

• To analyze the data and develop To analyze the data and develop preventive measures periodically.preventive measures periodically.

• To help identify areas needing To help identify areas needing improvement or recognitionimprovement or recognition

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WHEN TO USE OVR:WHEN TO USE OVR:

• Injury to visitors or volunteers Injury to visitors or volunteers while on the hospital premiseswhile on the hospital premises

•Any incident which is not Any incident which is not consistent to routine patient consistent to routine patient carecare

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WHEN TO USE OVR:WHEN TO USE OVR:• Occurrences not consistent with Occurrences not consistent with

routine operation of facility and /or routine operation of facility and /or adversely affects, threatens the adversely affects, threatens the health or life of patient, visitor, health or life of patient, visitor, employee, student or volunteer.employee, student or volunteer.

• Loss or damage to personal or Loss or damage to personal or hospital property.hospital property.

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WHO SHOULD WHO SHOULD REPORT?REPORT?

•Everybody Everybody

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RESPONSIBILITIES:RESPONSIBILITIES:

• The employee who witnesses or The employee who witnesses or discoversdiscovers– Immediate notification of Immediate notification of

attending physician in case of attending physician in case of injury and Immediate Supervisorinjury and Immediate Supervisor

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RESPONSIBILITIES:RESPONSIBILITIES:

•Attending PhysicianAttending Physician–Complete and document his/her Complete and document his/her

action (s) on the OVR form action (s) on the OVR form immediately upon carrying out his immediately upon carrying out his examination and/or the required examination and/or the required treatment or care.treatment or care.

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RESPONSIBILITIES:RESPONSIBILITIES:

• Immediate SupervisorsImmediate Supervisors–Consultation with the involved Consultation with the involved

employee (s)employee (s)–Resolution of problems should Resolution of problems should

take place when possible within take place when possible within and between departmentsand between departments

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RESPONSIBILITIES:RESPONSIBILITIES:

• Immediate SupervisorsImmediate Supervisors–Ensuring that all employees are Ensuring that all employees are

aware of OVR Reporting System; aware of OVR Reporting System; how to report and the steps by how to report and the steps by steps procedure on how to steps procedure on how to complete the form.complete the form.

–Conduct immediate action and Conduct immediate action and follow up after the incident occursfollow up after the incident occurs

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RESPONSIBILITIES:RESPONSIBILITIES:

• Immediate SupervisorsImmediate Supervisors–Document on the OVR the actions Document on the OVR the actions

taken and/or any corrective taken and/or any corrective measures, taken to prevent the measures, taken to prevent the recurrence of the eventrecurrence of the event

–Evaluates incident if meets Evaluates incident if meets sentinel event criteriasentinel event criteria

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RESPONSIBILITIES:RESPONSIBILITIES:• Immediate SupervisorsImmediate Supervisors– Forward the completed (original) OVR Forward the completed (original) OVR

report form to the Total Quality report form to the Total Quality Management office within 72 hours (3 Management office within 72 hours (3 days) of the occurrencedays) of the occurrence

– Conduct any further investigation and Conduct any further investigation and document, report investigated document, report investigated findings upon request of the Hospital findings upon request of the Hospital Administration the Quality Administration the Quality Management CommitteeManagement Committee

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RESPONSIBILITIES:RESPONSIBILITIES:

•The Total Quality The Total Quality Management Department Management Department –Monitoring all OVR for follow Monitoring all OVR for follow

upup–Trending and preparing a Trending and preparing a

monthly summarymonthly summary

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RESPONSIBILITIES:RESPONSIBILITIES:

•The Total Quality The Total Quality Management Department Management Department –Submitting a quarterly report Submitting a quarterly report

to the Quality Management to the Quality Management Committee for discussion and Committee for discussion and what action can be done in the what action can be done in the future to avoid recurrence.future to avoid recurrence.

–Upkeep the fileUpkeep the file

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RESPONSIBILITIES:RESPONSIBILITIES:• The Safety Officer The Safety Officer – Investigate all safety related incidentsInvestigate all safety related incidents–Organize a review team of selected Organize a review team of selected

Safety Committee members to Safety Committee members to investigate critical safety related investigate critical safety related occurrencesoccurrences

–Document the results of investigation Document the results of investigation and corrective action taken on the and corrective action taken on the OVR form and forwards it to the TQM.OVR form and forwards it to the TQM.

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OVR POLICYOVR POLICY• Report the details of any occurrence, Report the details of any occurrence,

which has an impacts in the care of which has an impacts in the care of patient.patient.

• OVR Form will be initiated immediately OVR Form will be initiated immediately after the incident. And submit it to your after the incident. And submit it to your immediate supervisor within the current immediate supervisor within the current work shift.work shift.

• All sections of the OVR form must be All sections of the OVR form must be completed and submitted to the completed and submitted to the immediate supervisor within the current immediate supervisor within the current work shift.work shift.

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OVR POLICYOVR POLICY• The report will not be used to The report will not be used to

criticize or blame the actions of the criticize or blame the actions of the staff involved.staff involved.

• Corrective actions shall be taken to Corrective actions shall be taken to minimize risk of injury and adverse minimize risk of injury and adverse outcomes. Corrective action (s) shall outcomes. Corrective action (s) shall be documented.be documented.

• The Occurrence report shall not be The Occurrence report shall not be placed in the medical record (Patient placed in the medical record (Patient File) nor in Employee File. File) nor in Employee File.

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OVR POLICYOVR POLICY• Confidentiality:Confidentiality:

All OVR shall be handled and All OVR shall be handled and maintained in a confidential maintained in a confidential manner with access to such manner with access to such documentation restricted to documentation restricted to authorized individuals.authorized individuals.

OVR shall not be duplicated, with OVR shall not be duplicated, with exception of the QM department, exception of the QM department, when deemed necessary.when deemed necessary.

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OVR POLICYOVR POLICYThe information contained in the The information contained in the

OVR form cannot and shall not be OVR form cannot and shall not be used against any individual as the used against any individual as the sole basis for disciplinary action.sole basis for disciplinary action.

The involved person’s MRN # The involved person’s MRN # instead of his/her name will be instead of his/her name will be used on the OVR form.used on the OVR form.

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OVR POLICYOVR POLICY Hospital staff is not at liberty to discuss Hospital staff is not at liberty to discuss

the content of an OVR or the events the content of an OVR or the events and circumstances relative to the and circumstances relative to the occurrence either with patient, visitor occurrence either with patient, visitor or other members of the staff, unless or other members of the staff, unless clarifying facts under investigation with clarifying facts under investigation with the proper authorities.the proper authorities.

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

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The OVR form should The OVR form should not:not:

Be PhotocopiedBe PhotocopiedBe Placed in Medical RecordBe Placed in Medical RecordBe DiscussedBe DiscussedBe given Personal OpinionsBe given Personal Opinions

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Do Not:Do Not:Use the names of Use the names of

involved/concerned person.involved/concerned person.Use the content of the OVR Use the content of the OVR

against any individual for against any individual for disciplinary action.disciplinary action.

Divulge any information Divulge any information written on the OVR form to written on the OVR form to unconcerned individuals & unconcerned individuals & media.media.

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EQUIPMENTS / FORMS:EQUIPMENTS / FORMS:

Occurrence Occurrence Variance Variance Report FormReport Form

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OVR FORMOVR FORM

DATE & TIME OF INCIDENT: _______________________WARD/ROOM/DEPARTMENT: ______________________DIAGNOSIS: _____________________________________

STATUS (CHECK ONE): ( ) IN-PATIENT ( ) OUT-PATIENT ( ) VISITOR( ) EMPLOYEE ( ) OTHER (SPECIFY): _____________________

MEDICAL RECORD NUMBER: _____________AGE: _____________SEX: __________________NATIONALITY: __________________________DATE & TIME RECORD INITIATED: ____________________________________________________________________________________

INTRAVENOUS RELATED( ) Central Line( ) Contrast Media Reaction( ) Extravasate( ) Occluded( ) Precipitate( ) Site Red/Swollen( ) Tubing Leak( ) Expired Fluid( ) Additive Related( ) Transfusion Reaction( ) Other __________________

PROCEDURE VARIANCE( ) Delay ( ) Missing Files/Notes( ) Performed on Wrong Site( ) Consent( ) Patient Identification( ) Wrong Patient( ) Wrong Procedure( ) Lost/Spoiled Specimen( ) No Response( ) Wrong File( ) Procedure Cancellation( ) Notes in Wrong File( ) Inadequate/Inappropriate entry( ) No Label/Addressograph( ) Other ___________________________BEHAVIOR( ) DAMA( ) Absconded( ) Dissatisfied with Care( ) Patient Behaivior( ) Family/Visitor Behaivior( ) Staff Behaivior( ) Borrowed Medical Record Card( ) Non-Compliance

HAZARD/SAFETY( ) Burn ( ) Chemical Spill( ) Electrical Shock( ) Fire( ) Gas( ) Hazardous Waste( ) Radiation Exposure( ) Chemical Splash( ) Water Spill( ) Other________________________

SECURITY VARIANCE( ) Damage/Loss of Property( ) Drug Count Variance( ) Drug Keys( ) Prescription Alteration( ) Security Problem( ) Suicide Attempt( ) Other ___________________

EQUIPMENT/SUPPLIES( ) Electrical Problem( ) Equipment Not Working( ) Mechanical Problem( ) Operator Not Qualified( ) Wrong Equipment( ) Missing Equipment( ) Not Available( ) Out of Stock( ) Other ___________________

ARAR CENTRAL HOSPITAL

PART A – ADDRESSOGRAPH

OCCURRENCE VARIANCE REPORT

(NOT PART OF THE MEDICAL RECORD)

OCCURRENCE TYPE

42PART B 2-1 – DESCRIBE THE OCCURRENCE (STATE THE FACTS)FACTUAL DESCRIPTION…………………………………………………………………………………………………………………………………………….…..…………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………….……………………………………………………………………………………………………………………………………………..………………Reported By: Name: ………….………………………..…..…. ID No. ………….… Dept. …………... Position………….……..Witness By: Name: ………………………………………….. ID No. ……….…… Dept. …….……... Position………………...IMMEDIATE ACTION: (PART B 2-2)Physician Notified: ( ) YES ( ) NO ( ) NOT APPLICABLEDid MD see patient: ( ) YES ( ) NOIf yes, investigation/s done: ( ) X-ray ( ) Suture ( ) Blood work ( ) Medication

Assessment/Diagnosis: (PART B 3-1)………………………………………………………………………………………………………………………….………………..…………………………………………………………………………………………………………………………………………….……..………

SEVERITY CODE (CHECK ONE) PART B 3-2( ) Minor - no injury or minor treatment (i.e. abrasion; no increased length of stay; no increased level of care)( ) Moderate - increased length of stay; increased level of care( ) Major - temporary or permanent lessening of body functions( ) Sentinel - catastrophic; death or major permanent loss of function( ) Near Miss - potentially severe outcome

IMMEDIATE ACTION (PART C)

Action taken by initiating department Action taken by the responding department

……………………………………………………………..……………………………………………………………………………..………………………………………………………………………..…………………………………………………………………..………………………………………………………………………..………………………………………………………………………..……………………………………………………………………..……………

………………………………………………………………………………………………………………………….………………………………………………………………….…………………………………………………………………….…………………………………………………………………….…………………………………………………………………….…………………………………………………………………….…………………

Head of Department:Date:

Head of Department:Date:

TQM OFFICE COMMENT: PART D……………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

OVR FORM (PAGE 2)

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SUMMARY OF SUMMARY OF LECTURE:LECTURE:• OCCOURANCEOCCOURANCE

• OVR (Definition)OVR (Definition)• ADVERSE EVENTADVERSE EVENT• VARIENCEVARIENCE• NEAR MISS (& Why it should be reported)NEAR MISS (& Why it should be reported)• SENTINEL EVENTS (Definition)SENTINEL EVENTS (Definition)• “ “ “ “ (Types)(Types)• “ “ “ “ (policy)(policy)• “ “ “ “ (Procedure)(Procedure)

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SUMMARY OF SUMMARY OF LECTURE:LECTURE:• How to deal with sentinel/adverse eventHow to deal with sentinel/adverse event

• Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR• Who should report /responsibilitiesWho should report /responsibilities (Employee, attending physician, immediate (Employee, attending physician, immediate

supervisor, TQM department, safety officer)supervisor, TQM department, safety officer)• OVR policyOVR policy• OVR form restrictions OVR form restrictions • OVR form sampleOVR form sample

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