dmc incident reporting 1 of 30 dmc incident reporting employee education competency module dmc...

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DMC Incident Reporting

DMC Incident ReportingEmployee education competency module

DMC Environment of Care DepartmentDetroit Medical Center©February, 2010

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Incident Reporting

All incidents, accidents, or occurrences that cause or could cause harm to an employee, patient or visitor in the DMC must be reported: See 1 CLN 026 Incident

Reporting

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Most events or errors happen because of process issues: Many “little” failures lead to a “bigger” event

Rarely a “person” failure

Incident Reporting – Process Issues

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The DMC supports a blame-free environment: All employees are encouraged to report all events and

occurrences.

By getting to the root cause of an error, we can fix the underlying system or process issues that allowed the event to happen.

Incident Reporting – Blame-Free Environment

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Patient Incident: Any patient related incidents, including lost or damaged patient belongings. NOTE: Ask yourself did the incident involve the patient? If ‘yes', then enter as a Patient Incident

Employee Incident: Any employee incident, including workplace conflict.

Visitor Incident: Any incident that involves or affects a visitor.

Property incidents related to employees or visitors should be reported directly to Security.

Types of Safety Incidents

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What to report: Error: An unintended event or act. This can be

something that was done or something that should have been done but wasn’t.

Near Miss: An event that was “caught” and caused no harm, but for which a recurrence carries a significant chance of harm.

Hazardous Condition: Any set of circumstances which significantly increase the likelihood of a serious adverse outcome.

Incident Reporting

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Patient Incidents

Patient incidents are events that involve the patient and include:

– Patient injury – falls, hospital acquired pressure ulcers or infection.

– Missed, delayed or wrong treatment/procedure.

– Medication events.

– Breach of confidentiality – HIPAA violations.

Patient incidents must be documented in the medical record and entered in the web-based reporting system:

– An objective note should be placed in the patient’s medical record documenting:

o The facts and events of the incidento Physician findingso Treatment

Do not document that an incident report has been filed or refer to the incident number.

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How to Report an Incident

The DMC uses a web-based incident reporting system (SRM) that allows our organizations to report and track patient, employee and visitor safety events and patient and family complaints (feedback).

To access web-based incident reporting:

1. Select the icon available on your DMC desktop marked ‘SRM’.

2. Select ‘Enter SRM’.

3. Find your site.

4. Select either ‘SRM’ for an patient, employee, or visitor safety event, or ‘Feedback’ to enter a patient or family complaint.

5. Answer every question to the best of your ability.

Paper down-time forms can be used in the event of problems with the web-based system.

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Adverse Drug Events: Adverse Drug Reaction: Unexpected, unintended, undesired or excessive response to a medication.

Medication Variance (Error): Any preventable event that may cause or lead to patient harm or inappropriate medication use.

Types of Safety Incidents

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Patient Incidents Involving Medical Devices

Medical Device Incidents: Are incidents in which a medical device may have caused a patient’s death, serious illness or injury or has critical information stored in it. A medical device can be a piece of equipment (IV pump, monitor, etc.) or a patient care item (i.e. Foley catheter).

When you have a defected device:

1. Remove the device from service, tag it and report the incident.

2. Keep the device on the unit.

3. Do not unplug the device, if it was plugged in.

4. Immediately notify Biomed – they must retrieve any data, as soon as possible.


See policy 1 CLN 017 Safe Medical Device Act.

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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 (See slide 12 for additional information).

Reviewable Event: An unexpected clinical event involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. Such events signal the need for immediate investigation and response and are also referred to as ‘Sentinel Events’ by the Joint Commission (See slide 13 for additional information).

Serious Reportable Event: Type of Reviewable Event that is a concern to both the public and healthcare providers – these are also referred to as ‘Never Events’ (See slide 14 for additional information).

Reviewable Event Recording

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Unexpected Clinical Events

All reviewable and serious reportable events are unexpected clinical events: Report immediately to the department manager and also enter into the web-based incident reporting system.

The manager will then immediately notify Risk Management, Quality and the Chief Medical Safety Officer.

Site quality personnel will notify corporate quality (a phone call to CQSO or the quality director) 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.

See policy 1 CLN 027 Unexpected Clinical Events.

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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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Serious Reportable Events – ‘Never Events’

Some examples of serious reviewable events include: All Joint Commission 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 healthcare facility.

Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility.

There are 28 NQF Serious Reportable Events. They are viewed and updated annually.

If a serious reportable event (never event) occurs, the DMC CQSO will notify Patient Finance Services who will waive all changes directly related to the event.

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An employee incident is an event occurring on the DMC premises that is not consistent with the employee’s routine work and may adversely impact their health, life, comfort, or property.

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 policy 1 HR 507 Prevention of Workplace Violence.

Employee Incidents

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All employee incidents are reported to the department manager and entered into the web-based incident reporting system.

The employee is to report to the Emergency Department or Occupational Health as per site protocol.

Reporting Employee Incidents

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Reporting Disruptive Behavior

Disruptive behaviors: Are behaviors that undermine a culture of safety. They can include verbal and non-verbal behavior, rude language, a threatening manner or physical abuse. Disruptive behavior by physicians, managers, other professionals or any other employees should be reported.

Disruptive behavior should be reported in SRM:

1. Select the icon available on DMC Citrix marked ‘SRM’.

2. Select ‘Enter SRM’.

3. Find your site.

4. Select ‘Employee Safety Incident’.

5. Search on ‘Behavior’ or ‘Serious Behavioral Issue’.

6. Select the correct description of what happened.


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As soon as it happens or as soon as you find out about it: - See 1 CLN 026 Incident Reporting Policy.

When Should You Report An Incident?

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Staff will enter any patient, visitor, employee, medication or workplace conflict related incidents or near misses into the 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.

Incident Reporting – Staff Responsibilities

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Incident Reporting – Management Responsibilities

If a paper form was used to report the incident, department managers or designee, will enter information into the web-based incident reporting system and destroy the paper form after entry.

Managers or their designees will review incidents involving their respective areas.

When investigating an incident, managers will:

– Interview employee(s) and if appropriate, determine additional factual information.

– Add any missing information regarding the circumstances.

– Review the 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.– Review events and have documented follow-up within 7 days of the

event’s entry.

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Incident Reporting – Management Responsibilities

Department manager, site administrator, risk management and the 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 policy 1 CLN 027 Unexpected Clinical Event for further information or direction.

Notify your site Safety Officer to report unsafe conditions or hazards.

Report any employee lost time to Human Resources/Regional Workers’ Compensation Administration within 24 hours of the incident.

Identify, implement, educate and document actions taken to lessen likelihood of incident recurring.

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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: Review incidents.

Close all events with level of impact category F or higher:

- If an event is referred to peer review, or a RCA/IA is being conducted, Clinical/Quality Improvement will document the statement in the ‘follow-up’ section of the incident report.

Incident Reporting – Other Department Responsibilities

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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.

Patient, Family and Visitor Complaints

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Definitions: Medical Grievance: Any complaint (written or verbal) that

involves treatment or care of the patient, including complaints against physicians.

Complaint: Any expression of dissatisfaction related to an occurrence that is not able to be resolved to the satisfaction of the patient/family at a department 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 department level (some examples include food temperature, TV or phone problems).

Patient, Family and Visitor Complaints

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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 Feedback.

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Complaint Management

The Patient and 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.

They will offer assistance and intervention in bringing the matter to closure: The Patient and Guest Relations Manager closes all complaints entered into the web-based incident reporting system.

See policy 1 CLN 033 Patient and Family Grievances and Complaints.

Complaint management results data is used to identify opportunities for improving patient/family services throughout the Detroit Medical Center.

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For reporting non-environmental issues such as harassment.

Calls can be placed by patients, visitors or employees.

Reporting may be done anonymously.

For immediately report hazardous conditions and other environment of care issues (examples – icy walkways, elevator problems):

- You may also call your site Safety Officer.

Compliance Hotline – 1.888.484.9200

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As employees of the DMC, it is everyone’s responsibility to ensure safe, quality care for our patients.

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 your concerns are not addressed, you have the right to contact the Joint Commission at:

View website: www.jointcommission.org/GeneralPublic/Complaint Send an e-mail to: [email protected] Use the Office of Quality Monitoring fax number: 630.792.5636

Quality of Care

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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.

Course Summary

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We hope this NetLearning course has been both informative and helpful. Please feel free to review this course until you are confident about your knowledge of the material presented.

Click the Take Test button, located on the left side of the screen, to complete the requirements for this course.

For future reference this module is available on the NetLearning Library under the 2010 Core Compliance category. The NetLearning Library link is found on the DMC Intraweb screen under the NetLearning drop-down list.

Thank You

dmc incident reporting 1 of 30 dmc incident reporting employee education competency module dmc...

Documents

incident reporting slide

visitor incident

incident number

dmc desktop

track patient

patient related incidents

webbased reporting system

patient injury falls