health care events reporting system

Professional Nursing Today

Introduction to Nursing ReportingHealthcare Delivery System

Professional Nursing Today

Introduction to Nursing ReportingHealthcare Delivery System

What makes a nurse a professional?What makes a nurse a professional?

Components:Components:

Scope & Standards of PracticeScope & Standards of Practice The process of reporting the events occurred

within the healthcare facilities. It starts by discovering the event by any staff.(Discoverer)

All staff is encouraged and accountable to report any discovered deviation in the performance or process outputs or outcomes of healthcare services whether or not led to harm.

Non punitive response to error reporting is supported by the facility leaders except for the misbehavior and for proved negligence.

It ends by decision making for improvement at the level of General Directorate.

CONTINUED:CONTINUED:

For confidentiality:

1- No duplication or photocopy is allowed for any filled form of the common formats.

2- The filled form must not be part of the staff or patient records files.

3- The filled forms are not legal document, used only for study and quality improvement

purposes.

CONTINUED:CONTINUED: Some of the data entered in the manual

common formats are highlighted by shading to indicate their confidentiality for the

healthcare facility use ONLY and not to be shared outside.

The event reporting is collaborative teamwork approach uses the common

formats guided by the quick user guide.

CONTINUED:CONTINUED: The Common Formats are not an attempt to replace

any current mandatory reporting system, collaborative/ voluntary reporting system, research-related reporting system, or other reporting/recording system in the healthcare facility. They are intended to facilitate the collection, aggregation, and use of patient safety data regardless of the type of reporting system.

CONTINUED:CONTINUED:

If the event is discovered during its occurrence, the

discoverer must first contain the event and

mitigate its risk to prevent its consequences. Communication of the events’ information should

be encouraged between the staff working within the facility “on need to know basis” with emphasis on “how” and “results” more than “what” and “who”.

CONTINUED:CONTINUED:

Common formats data must be validated by the responsible quality officer for their reliability.

Purpose:Purpose:Establish system and set

responsibilities and accountabilities regarding:

Reporting of patient safety events happening during healthcare provision,

Events Data analysis and, Events Information Communication.

IncidentIncidentA type of a patient safety event that

reaches the patient, whether or not the patient was harmed.

Near Miss An event or situation that could

have resulted in an adverse event but did not either by chance or through timely intervention.

Sentinel EventSentinel Event A Sentinel Event is an unexpected occurrence

involving death or serious 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 are called”sentinel”because they signal the need for immediate investigation and response.

CONTINUED:CONTINUED: Sentinel (Serious reportable) events

after its confirmation as sentinel event or near miss sentinel event category must:

1- Be notified to the facility management immediately.

2- Do a root cause analysis done by multidisciplinary team maximum within

7 working days.

3- A thorough and credible action plan done maximum within 45 days.

CONTINUED:CONTINUED: Proactive approach using FMEA(failure mode

event analysis) will be used for the high risk processes that are identified from data analysis and lessons learnt from other organizations in

the network.

Role of the SupervisorRole of the Supervisor

5:Investigate and

Document upon

request