patient safety reporting program asc adverse … safety reporting program asc adverse event...
TRANSCRIPT
Patient Safety Reporting Program
ASC Adverse Event Reporting Form
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Last updated: May 2015
General Information Indicates a required field.
Event date Event time
Date discovered
Use military time (hhmm)
Time unknown Date quality/risk/patient
safety notified of event.
Patient’s gender Patient’s age
Check one. Please use the patient’s self-identified gender.
In Years Months Weeks Days
Male
Circle one.
Female
Patient’s race Check all that apply.
Patient’s ethnicity
Check one.
American Indian or Alaskan Native
White
Other
Unknown
Hispanic
Not Hispanic
Unknown Asian
Black or African American
Native Hawaiian Pacific Islander
Contact name Contact email address Contact phone Who should we contact for clarification or feedback?
, ext.
Facility Name
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 2 of 10
Harm Category The Harm Category for this event is: Check one. Please answer the questions on page 3 to determine your Harm Category. These questions follow the Harm Category Algorithm developed by NCC MERP. If you choose more than one event type, please select the highest applicable level of harm.
A. Circumstances that have capacity to cause error
B. Event did not reach patient (an 'error of omission' does reach the patient)
C. Event reached patient but did not cause patient harm
D. Event reached patient and required monitoring to confirm that it resulted in no harm and/or required intervention to preclude harm
E. Event may have contributed to or resulted in temporary harm but did not require a significant intervention
F. Event may have contributed to or resulted in temporary harm and required a significant intervention
G. Event may have contributed to or resulted in permanent patient harm
H. Event required intervention necessary to sustain life
What was the extent of harm to the patient? Check one. Which best describes the extent to which the patient's functional ability is expected to be impaired, based on your present assessment of the patient's future condition attributable to the event, taking the likely effects of treatment into account?
Severe harm: bodily injury (including pain or disfigurement) that interferes significantly with functional ability or quality of life
Moderate harm: bodily injury adversely affecting functional ability or quality of life, but not at the level of severe harm
Mild harm: minimal symptoms or loss of function, or injury limited to additional treatment, monitoring, and/or increased length of stay
I. Event may have contributed or resulted in patient's death
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 3 of 10
Harm Category
Did an actual adverse event occur?
Circumstances that have the capacity to cause an adverse event
Category A
Did the event reach the patient?*
Did the event contribute to or result
in patient death?
Category I
Was the patient harmed?
Category C
Category D
Was extra monitoring or an intervention to
preclude harm required?
Was an intervention necessary to sustain life
required?
Was the harm permanent?
Category H
Was the harm temporary?
Category G
Adverse Event An event resulting in unintended harm or creating the potential for harm that is related to any aspect of a patient’s care (by an act of commission or omission) rather than to the underlying disease or condition of the patient; adverse events may or may not be preventable
Harm Any physical injury or damage to the health of a person and/or pain resulting therefrom, including both temporary and permanent injury
Permanent Harm Harm lasting more than six months or where the end harm is not known
Monitoring To observe or record physiological or psychological signs
Intervention May include change in therapy or active medical/surgical treatment
Intervention Necessary to Sustain Life Includes cardiovascular and/or respiratory support (e.g., CPR, defibrillation, intubation)
Significant Intervention An intervention intended to relieve symptoms that have the potential to be life-threatening if not addressed
*An error of omission does reach the patient
Which intervention to preclude harm was required? Check all that apply.
Prolonged postoperative stay
Monitoring, including observation, physiological examination, laboratory testing, phlebotomy, and/or imaging studies
Medication therapy (excluding administration of rescue drug or antidote)
Other intervention (please describe)
Did the event require any of the following significant interventions? Check all that apply.
No significant intervention
Hospital admission
Prolonged postoperative stay
Surgical/procedural intervention
Respiratory or cardiovascular support (e.g., ventilation, tracheotomy)
Unplanned blood transfusion
Medication therapy (including administration of a rescue drug or antidote)
Other significant intervention (please describe)
Category E
Category F
Category B
What prevented the event from reaching the patient? Check one.
Fail-safe/safeguard worked effectively
Action by practitioner or staff who made the error prevented the event from reaching the patient
Action by practitioner or staff (other than person making the error) prevented the event from reaching the patient
Action by patient or patient’s family member prevented the event from reaching the patient
Unknown
Other (please describe)
Yes
No
No
No
No
No
No
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
No
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 4 of 10
Event Information Indicate the type of event that you are reporting (select at least one). Events in bold are considered reportable events regardless of harm category.
Once you have selected the event type, scroll down the page and complete the "Additional Event Information" section as well as the additional questions specific to the event type you selected (noted with an * by event type).
Event Type Check only one. If the event consists of multiple event types, select only the precipitating event that best describes the situation. In rare cases, reports may involve two distinct adverse events in which case multiple adverse events may be selected.
Air embolism
Anesthesia*
Aspiration
Blood or blood product (including hemolytic reactions)*
Burn (unrelated to the use or misuse of a device or medical/surgical supply)
Care delay (including delay in treatment, diagnosis)
Contaminated drugs, devices or biologics*
Contaminated, wrong or no gas given to a patient
Deep vein thrombosis with or without pulmonary embolism
Device or medical/surgical supply (including use error)*
Electric shock
Fall*
Healthcare-associated infection (HAI) (including surgical site infections up to 30 days postoperatively)*
Irretrievable loss of irreplaceable biological specimen
Medication or other substance*
Restraint or bedrail related
Surgical or other invasive procedure (including unplanned admission to hospital, unplanned emergency department visit, incorrect site, incorrect patient, incorrect procedure, etc.)*
Unintended retained foreign object (includes retained surgical items)*
Other event (please describe)
* This event type triggers additional event-specific questions that appear below “Additional Event Information.”
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 5 of 10
Additional Event Information Event Location Select the location where the event occurred, or originated, regardless of the location in which it was discovered.
Bathroom (toileting, bathing, tub/shower room)
Operating/procedure room
Preop area
Post anesthesia care unit
Patient home, post discharge
Other (please describe)
Relevant surgeries or procedures Please list surgeries or procedures that preceded the reported event, or during which the reported event occurred (e.g., knee surgery, central line insertion).
Admitting diagnosis Only indicate primary diagnosis. ICD-9 /ICD-10 not required.
Relevant comorbidities Please list co-morbidities related to the reported event.
What was the patient's documented ASA class? Only events involving an invasive procedure for which ASA Class was not determined should mark ‘n/a.’
Class 1
Class 2
Class 3
Class 4
Class 5
Unknown
n/a
How preventable was the incident? Choose one
Almost certainly could have been prevented
Likely could have been prevented
Likely could not have been prevented
Almost certainly could not have been prevented
Unknown
Was the event associated with HIT (Health Information Technology)? Check one.
Yes – go to page 6
No – go to page 7
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 6 of 10
Type of HIT device involved Check one.
Automated dispensing system (e.g.,
pyxis)
EHR or component of EHR Type of EHR involved
Human interface device (e.g., keyboard, Check one.
monitor/display, speech recognition system)
Laboratory information system, including microbiology and pathology systems
Radiology/diagnostic imaging system (including PACS)
Computerized provider order entry (CPOE) system
Pharmacy system
Clinical documentation system (e.g., progress notes)
Clinical decision support (CDS) system
Electronic medication administration record (eMAR)
Other (please describe)
Other (please describe)
Which of the following describes the circumstances involving the HIT in the event? Check all that apply.
Incompatibility between devices Which problem(s) resulted from the HIT function problem?
HIT function Check all that apply.
HIT maintenance Loss or delay of data Incorrect test results
Hardware failure or problem System returns or stores data that does
not match patient
Image measurement/corruption issue
Image orientation incorrect
Incorrect software programming calculation
Incorrect or inappropriate alert
Other (please describe)
Network failure or problem
Security, virus, or other malware issue
Unexpected software design issue
Human/device interface or other ergonomics issue
Which human/device interface or ergonomics issue(s) were involved? Check all that apply.
Unknown
Other (please describe) Hardware location (e.g., awkward placement for use)
Data entry or selection (e.g., entry or selection of incorrect patient, incorrect provider, incorrect drug, incorrect dose)
Alert fatigue/alarm fatigue
Information display or interpretation (e.g., font size, color of font, location of information in display screen)
Other (please describe)
The following event types have additional questions that are available in separate documents on our website.
Anesthesia
Blood or blood product
Contaminated drugs, devices or biologics
Device or medical/surgical supply
Fall
Healthcare-associated infection (HAI)
Medication or other substance
Surgical or other invasive procedure
Unintended retained foreign object
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 7 of 10
Contributing Factors What were the most important contributing factors to this event? Select all factors that apply. Select "No" if the factor does not fit the event. Selecting "Yes" will provide you with a more detailed list of related factors to choose from. If the list does not include an applicable contributing factor, select "other" and briefly describe the factor in the space provided.
Communication Were communication factors involved in this event?
Yes Healthcare team member factors Patient/family factors
No Check all that apply Check all that apply
Across units Culture
Among interdisciplinary teams Language
Between providers and staff Miscommunication
Between supervisor and staff Patient did not use call light
Handoffs, handovers, or shift reports Patient unable to communicate
Hard to read fax or handwriting Understanding discharge instructions or plan
Within units Other (please describe)
With other organizations or outside providers
Other (please describe)
Device, equipment, and supply Were device, equipment, or supply factors involved in this event?
Yes Device, equipment, or supply factors
No
Check all that apply.
Availability Shortage
Design Use or selection by healthcare provider or staff
Function (e.g., defective, non-working) Use by patient
Maintenance Other (please describe)
Human and environmental Were human or environmental factors involved in this event? Human factors refers to healthcare professionals and staff only. For patient factors, use the Patient Factors category below.
Yes Human and environmental factors
No Check all that apply.
Alarm fatigue Provider or staff fatigue
Clutter Provider or staff health issues
Interruptions or distractions Provider or staff stress
Lighting Work area design and specifications
Noise Other (please describe)
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 8 of 10
Organizational Were organizational factors involved in this event?
Yes Organizational factors
No Check all that apply.
Adequacy of budget Management or leadership skills
Assignment or work allocation Staff competencies
Clinical supervision Staffing levels
Culture of safety Systems to identify risk
Internal reporting Temporary staffing
Job orientation or training Other (please describe)
Managerial supervision
Policy or procedure Were policy or procedure factors involved in this event?
Yes Policy or procedure factors
No Check all that apply. Includes order sets, protocols, checklists, policies, and procedures.
Clarity of policy or procedure Policy or procedure too cumbersome
Policy or procedure absent Work-around more efficient
Provider/staff unfamiliar with policy or procedure
Other (please describe)
Patient management Were patient management factors involved in this event?
Yes Patient management factors
No Check all that apply.
Initial diagnosis Patient assessment
Treatment or care plan Follow-up care
Response to changing condition or delay in care
Other (please describe)
Patient Were patient factors involved in this event?
Yes Patient factors
No Check all that apply.
Behavioral status Physical limitations
Family dynamics or relationships Sensory impairment (vision, hearing, balance, etc.)
Fragile health status Other (please describe)
Mental status
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 9 of 10
Review Date review and analysis completed MM/DD/YYYY
Members of the review and analysis team Check all that apply.
Anesthesia provider
Engineering/biomed/materials management
Family/patient/patient representative
Health information technology/information service
Nursing management
Nursing staff
Physician(s)
Quality management
Senior management/administrator
Other (please describe) ________________________________________________________________
Person hours spent in review Please approximate the combined total number of hours that all individuals involved contributed to the review and analysis of this event.
Who was notified of this event? Check all that apply
Administrator
Senior management
Board of directors
None of these were notified
Did the review and analysis team have a post-analysis briefing with senior management? Either in person (with the whole team or a single representative) or through a senior leader review of the analysis findings and outcomes.
Yes
No
Who was given written notification of this event? Check all that apply.
Patient Please specify why no written notification was given. Check all that apply.
Patient’s representative
None given Written notification pending
No organizational policy
Not required by facility organizational policy
Not required by Commission definitions
Oral disclosure
Unable (please describe)
Other (please describe)
Oregon Patient Safety Commission
CONFIDENTIAL OR PRIVILEGED: This document contains confidential and privileged patient safety data pursuant to ORS 442.820 to 442.835 and Sections 1, 4 to 6, 8 to 10, and 12, Chapter 686, Oregon Laws 2003. Page 10 of 10
Summary
Summary, Causes, & Preventive Action Plans
The Commission evaluates reports to support healthcare organizations in conducting in-depth investigations focused on preventing future adverse events. Acceptable quality is determined using four criteria: completeness, thoroughness, credibility, and effective action plans (see the Quality Criteria document in the Tools and Resources menu above).
Please do not use patient, provider, or facility names to describe the adverse event. If you want to refer to a specific healthcare provider, please use general terms (for example, use a generic description, such as doctor or nurse 1).
Complete account Briefly summarize the circumstances leading up to the event. The summary should describe the role contributing factors played and the system practices and processes involved, and may briefly describe relevant patient clinical progress. Include enough information so that someone unfamiliar with the event could easily understand how the event happened.
For the following questions, identify up to five causes and associated action plans that your organization will take to prevent occurrence of similar events. Include at least one root cause and one system-level action plan. Show a clear link between the cause and the action plan. A root cause identifies underlying processes and gaps in practice related to the event. A system-level action plan focuses on processes, practices, and procedures, rather than individuals, and has the greatest likelihood of preventing future occurrences. (Note: you do not need to describe your implementation plan.)
This blank report is intended to be used as a reference only. You cannot submit this form. Please login to the Patient
Safety Reporting Program (PSRP) online system to submit a report (http://psrp.oregonpatientsafety.org/)
The following event types have additional questions that are available in separate documents on our website.
Anesthesia
Blood or blood product
Contaminated drugs, devices or biologics
Device or medical/surgical supply
Fall
Healthcare-associated infection (HAI)
Medication or other substance
Surgical or other invasive procedure
Unintended retained foreign object
Causes Root cause? Action Plans
Yes No
1.
2.
3.
4.
5.