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Occurrence Variance

Report/Sentinel Event Reporting

Occurrence Variance Report/ Sentinel Event Reporting MELANIE RODRIGUEZ,RN

MELANIE RODRIGUEZ,RN

Introduction

Being an accredited organization is not about being a mistake/error free one.

It is about having a system to detect, report, solve and uproot the causes of these errors as well as acknowledge that we are all humans,

but we are not afraid to face and fix our

mistakes.

Barriers That Need To Be Overcome

lack of awareness of the need to report, what to report, and why;

lack of understanding of how to report;

staff feel they are too busy to make a report;

too much paperwork involved in reporting;

the patient recovers from the adverse event and the urgency goes out of the situation;

fear of 'point-scoring' by colleagues, retribution by line management, disciplinary action or litigation;

an assumption that someone else will make the report; no evidence of timely feedback and/ or corrective action being taken resulting from making a report

CBAHI Requirements

There are around 14 standards across the CBAHI chapters that require presence of reporting of occurrences, events, incidents, or accidents.

FMS.5 Establishing a Safety committee consisting of the following representatives -head of safety, head of security, head of housekeeping, head of ER, head of Biomedical, head of maintenance department, Representative from lab, infection control, Nursing, TQM and

FMS.5.1 Meets at least 10 times/year on a monthly schedule, minutes documented.

FMS.5.2

Discusses and analyzes all safety issues.

FMS.5.3 Reviews summary of the incidents/ OVR reports and errors with high level of occurrence and suggests the

appropriate solution.

FMS.5.4

Reports Safety committee minutes to the hospital Director.

FMS.5.5

Communicates in writing with all Heads of Departments about the

risk issues in their areas.

LB.67 The lab develops the quality indicators to evaluate and detect problems. These following quality indicators are monitored:

LB.67.1. Incident reports.

LB.67.2. Turn around time for lab test. LB.67.3 Specimen identification errors. LB.67.4 Corrected Pathology and lab result reports.

PH.37 There is a process for monitoring, detecting, and reporting adverse drug reactions (ADRs) and includes:

PH.37.1

Written policy and procedure for ADR.

PH.37.2

Definition of a significant or serious ADR and timeframe for

reporting.

PH.37.3

ADR reporting forms are available

PH.37.4

Intensive analysis is performed for all significant or serious ADRs.

PH.37.5

Notification of treating physician.

PH.37.6

There is evidence that the patient receives appropriate care for

the ADR.

PH.37.7

There is evidence that the medical record has been flagged for

known allergies.

PH.37.8.

Process for improving ADR reporting.

PH.37.9.

Evidence of reporting any serious or unexpected ADR to the

MOH.

PH.38 There is a process for monitoring, identifying and reporting significant medication errors & includes:

PH.38.1

Written policy and procedure for medication error

reporting. PH.38.2

Definition of a significant medication error, timeframe

for reporting, and reporting format.

PH.38.3 PH.38.4

Evidence of active reporting exists.

Intensive root-cause analysis is performed for all

significant medication errors.

PH.38.5

Evidence for using reported data to improve

medication use process and reduce error rate.

PH.38.6

Mechanisms to prevent serious medication errors (e.g.

removal of concentrated intravenous potassium, magnesium,

hypertonic saline, other high risk stocks from nursing units).

IC.47 Infection control team monitors incidence of exposure of the staff to pathogens in the Hospital:

IC.47.1 There is a system for reporting, follow up & management of exposure to open pulmonary TB.

IC.47.2 There is a system for reporting, follow up & management of needle stick & sharp injuries.

IC.47.3 There is a system for reporting, follow up & management of exposure vaccine-preventable viruses (chickenpox, measles, mumps, and rubella).

IC.47.4 PPD conversion rates and sharp injuries rates are calculated.

NR.11 The Nurse Leader develops a Quality Plan that is consistent with the overall Hospital Quality Management Plan and ensures essential monitoring is done and this

includes but is not limited to the following:

NR.11.1 NR.11.2 NR.11.3 NR.11.4 NR.11.5

Medication errors. Patient falls. Pressure ulcers.

IV therapy (adherence to the policy).

Hand washing (adherence to the policy).

NR.11.6

Nurses role in cardiopulmonary resuscitation (adherence

to the policy). NR.11.7 Infection Control.

NR.22 There is a system for coordinating nursing activities after duty hours to handle administrative and

clinical issues which includes but is not limited to:

NR.22.1

Patients who present with or demonstrate

medical/surgical emergencies or change of condition.

NR.22.2 NR.22.3 NR.22.4 NR.22.5 NR.22.6

Dying patients.

Violent patients. All incident reports completed by nurses. Any adverse medication incidents.

Any Sentinel events.

NR.36 Nursing follows the occurrence variance reporting mechanism of the hospital that includes the following written procedures:

NR.36.1 List of reportable occurrences (medication error, patient fall, wrong procedure, etc.) NR.36.2 identifies the person responsible for initiating the report. NR.36.3 Identifies who is responsible for investigating the Occurrence.

NR.36.4 Describes how the occurrence is to be investigated (i.e. algorithm).

NR.36.5 Outlines the expected corrective action plan and assigned responsibility.

NR.36.6 Outlines the review process.

MS.11 The Medical Director works closely with the Quality Management Director/leader and Risk Manager in handling all near misses and incidents and:

MS.11.1

Root cause analysis is performed when

appropriate.

MS.11.2 Emphasis is placed on improving systems.

MS.11.3

The “Actions taken” are documented

MS.12 The Medical Director together with the department heads and Quality Director, monitors departments for the following:

MS.12.1 Patient assessments. MS.12.2 Adverse events. MS.12.3 Conscious sedation MS.12.4 Quality of medical records. MS.12.5 Medication errors. MS.12.6 Sentinel events.

MS.12.7 High-risk services and procedures (e.g. angiogram, ERCP, etc).

LD.40 The hospital has the essential administrative policies and procedures that are reviewed and updated every (2) years, that includes but are not limited to:

LD. 40.1 Sentinel event.

LD. 40.2 Incident report or occurrence, variance report (OVR).

LD. 40.3 Medico-legal cases.

LD. 40.4 Child Abuse.

LD. 40.5 Patient rights.

LD. 40.6 Code of conduct for staff.

LD. 40.7 Informed consent.

LD. 40.8 Conscious sedation.

LD. 40.9 No code or don’t resuscitate policy.

LD. 40.10 Dress code.

LD. 40.11 Admission, transfer and discharge.

LD. 40.12 Transfer to another facility.

LD. 40.13 Handling, use and administration of blood and blood products.

QM.25 There are outcome measurements (indicators) based on the mission and scope of services that may include but is not limited to:

QM.25.9 Adverse events (falls, injuries, pressure ulcers).

QM.11 The hospital has an incident reporting system (occurrence /variance /accident) Policy and form (OVA)

that staff follow and use when reporting adverse

events.

QM.11.1 Written policy on hospital incident reporting system (OVR)

QM.11.2 Availability of hospital incident reporting form QM.11.3 Evidence of Aggregated Incident reports

Functions of Quality

Department

setting and maintaining the standards and requirements for reporting in conjunction with the CBAHI;

collecting, collating, categorizing and coding adverse event information from all departments

assimilating other safety-related information from a variety of existing reporting systems and other sources

analyzing information on adverse events and maintenance of confidentiality of OVR

examining and tracking patterns and trends and acting on their findings where risks are identified;

providing feedback to organizations and individuals, including issue of 'patient safety alerts' to improve safety and quality;

producing solutions to reduce risk and prevent harm to future patients and specifying national goals and targets;

promoting a reporting culture within ShGH; collaborating with relevant bodies.

Purpose

Occurrence Variance Report is used to help identify areas needing improvement or recognition

ثداحلا رٌرقت مدختسٌ ةفرعمو دٌدحت ًف ةدعاسملل رٌوطتلل ماسقلأا ةجاح.

Occurrence Variance

Reports (OVR) are internal forms used to

document the details of the incident and the investigation of an

occurrence and the corrective actions taken.

ةٌلخاد تارامتسا نع ةرابع لٌصافت قٌثوتل مدختست كلذ ًف قٌقحتلاو ثداحلا

ًحٌحصتلا ءارجلإا ذاختاو مزلالا.

When to use ؟دختست ىتم

Injury to visitors or volunteers while on the hospital premises ىنبمب مهدجاوت ءانثأ نٌعوطتملا وأ راوزلا ةباصإ ىفشتسملا. Any incident which is not consistent to routine patient care ضٌرملاب ةٌانعلا نٌتور عم ضراعتت ةثداح يأ.

  • Occurrences not consistent with routine operation of facility and /or

adversely affects, threatens the

health or life of patient, visitor, employee, student or volunteer.

وأ ةٌنٌتورلا

ىفشتسملا تاٌلمع عم ةضراعتملا

ثداوحلا

رئازلا وأ ضٌرملا ةاٌح وأ ةحص ددهٌ امو ةٌبلسلا تارثؤملا عوطتملا وأ بلاطلا وأ ؾظوملا وأ.

  • Loss or damage to personal or hospital property.

ىفشتسملا تاكلتمم وأ ةصاخلا تاكلتمملا ررضت وأ نادقف.

Who should report

؟؟؟ػلبٌ نأ هٌلع بجٌ نم

Everybody

عٌمجلا/ لك ىلع بجٌ صخش.

What to report

اذام نع

؟غلبت

  • Medication related issues

  • Narcotics issue

  • IV related

  • Transfusion

  • Laboratory related

  • OR related

  • Radiology related

  • Breaks in standard precautions

.ةجلاعملاب ةقلعتملا روملأا .ةردخملا ةٌودلأا .ةٌدٌرولا لٌلاحملا . مدلا لقن ربتخملا تاقلعتم تاٌلمعلا ؾرؼ تلاكشم ةعشلاا

ةٌاقولا رٌٌاعم ًف للخ ىودعلا ةحفاكمو

Hospital acquired injury Fall/Slip Medical/Clinical Care Patient Identification/Labeling errors Medical Records Documentation Unauthorized Discharge Fire & Safety Security Variance

ىفشتسملا تاباصإ قلازنلاا/ طوقسلا .ضٌرملل ةٌداٌعلا/ةٌبطلا ةٌانعلا ضٌرملا ؾٌنصتو ؾٌرعت ءاطخأ ةٌبطلا تلاجسلا قئاثولا ةٌلوئسملا ءلاخإ عم جورخلا ةملاسلاو قٌرحلا ةٌنملأا تافلاتخلاا

Actual cases

  • Wrong labeling of blood samples

  • Suture needle broken

  • Delay in delivery of patient meals.

  • Encoding of medicines

  • Smoking inside the hospital premises

  • Patient/visitors tripping

  • Wrong Blood

  • Newborn’s identity

ةيعقاو تلااح

.مدلا تانٌعل ئطاخلا ؾٌنصتلا .ةروسكملا زرؽلا ةربإ تابجو مٌلست ًف رٌخأتلا .ضٌرملا .رتوٌبمكلا ًف ءاودلا لاخدإ مدع .ىفشتسملا قفارم لخاد نٌخدتلا .راوزلا وأ ىضرملا رثعت .ةئطاخلا مدلا ةئف .ددجلا دٌلاوملا ؾٌرعت

RESPONSIBILITIES

تايلوئسملا

  • 1. Supervisors and management personnel

  • 2. :ةرادلاا ًفظومو نٌفرشملا

    • - Consultation with involved employee(s).

.نٌٌنعملا نٌفظوملاب عامتجلاا -

  • - Resolution of problems should take place when possible within and between departments

نٌب نكمم تقو برقا ًف عضوت نا بجٌ ثٌح لكاشملل لولحلا عضو - .ماسقلأا

Responsibilities

تايلوئسملا

2. The employee who witnesses or discovers

:ثداحلا وفشتكا وا ودهاش نٌذلا نٌفظوملا.2

- Immediate notification of Physician on call and Section Supervisor

.مسقلا ؾرشمو بوانملا بٌبطلل رشابملا ملاعلاا -

3. Immediate Supervisor

:رشابملا ؾرشملا .3

-Ensuring that all employees are aware of OVR Reporting System; how to report and the steps by steps procedure on how to complete the form.

  • - ةئبعتو ػٌلبتلا ةٌفٌكو ثداوحلا رٌرقت ماظنل نٌفظوملا ةفرعم نم دكأتلا .ةوطخب ةوطخ ثداحلا رٌرقت ةرامتسا

- Conduct immediate follow up after the

incident occurs.

  • - .ثداحلا عوقو دعب ةرشابم ةٌروف ةعباتمب مق

3. Immediate Supervisor

:رشابملا ؾرشملا .3

- Document on the OVR the actions taken and/or any corrective measures, taken to

prevent the recurrence of the event.

  • - ةٌحٌحصت سٌٌاقم يأ وأ ذختملا ءارجلإا ثداحلا رٌرقت ًف بتكا .ثداحلا اذه لثم ثودح عنمتل تذختا

3. Immediate Supervisor

:رشابملا ؾرشملا .3

- Forward the completed OVR report form to

the Quality Management office within 72 hours

(3 days) of the occurrence.

  • - ثلاث( ةعاس 72

.ثداحلا نم )ماٌأ

ّ

للاخ ةدوجلا بتكم ىلإ ثداحلا رٌرقت ةرامتسا م

لس

3. Immediate Supervisor

:رشابملا ؾرشملا .3

- Conduct any further investigation and document, report investigated findings upon

request of the Hospital

Administration the

Quality Management Committee or the Safety

Committee.

ةرادإ نم بلط ىلع ءانب قٌقحتلا تادوجوم قٌثوتو ًفاضإ قٌقحت يأ لمعب ماٌقلا .ةملاسلا ةنجل وا ةدوجلا ةرادا ةنجل ىفشتسملا

4. Physician

:ءابطلأا .4

- Documenting a brief statement of

his/her action(s) on the OVR form

immediately upon completing his

examination and/or the required treatment or care.

رٌرقت ةرامتسا ىلع ذختملا ءارجلإا نع رصتخم صخلم قٌثوت

ةبولطملا ةجلاعملا ءادأ وأ هرابتخا ءاهنإ روف ةرشابم ثداحلا

.

:نع لوئسم ىضرملا ةملاسو ةدوجلا مسق نإ

.ةلمتكملا رٌؼ ثداوحلا رٌراقت لك ةعباتم

-

.يرهش صخلم عضوو زٌهجت

-

5. The Quality and Patient Safety Advocacy Department is responsible for:

- Monitoring all OVR for follow up.

- Trending and preparing a monthly

summary

:نع لوئسم ىضرملا ةملاسو ةدوجلا مسق نإ

ةشقانملل ةدوجلا ةرادإ ةنجل ىلإ يونس عبر رٌرقت مٌلست ثداوحلا يدافتل ةٌلبقتسملا تاططخملا عضوو

-

.ؾلملا / رٌرقتلا ىلع ظافحلا

-

5. The Quality and Patient Safety Advocacy

Department is responsible for:

- Submitting a quarterly report to the

Quality Management Committee for

discussion and what action can be done

in the future to avoid recurrence.

- Upkeep the file

:ةملاسلا مسق -6

.ثداحلا تاقلعتم عٌمج ةملاس نم ققحتلا

-

ءادبلإ ةملاسلا ةنجل ءاضعأ نم هعجارم قٌرف مٌظنت .ثداحلاب ةقلعتملا ةملاسلا تاظحلام

-

6. The Safety Dept

- Investigate all safety related incidents

- Organize a review team of selected

Safety Committee

members to

investigate critical safety related

occurrences.

:ةملاسلا لوؤسم -6

ةٌحٌحصتلا تاءارجلإاو قٌقحتلا جئاتن قٌثوتب ماٌقلا مسق ىلإ اهملسو ثداحلا رٌرقت ةرامتسا ًف ةذختملا .ىضرملا ةملاسو ةدوجلا

-

6. The Safety Officer

  • - Document the results of investigation and corrective action

taken on the OVR form and

forwards it to the QPS dept.

Policy

ةسايسلا

1. Report

the

details

of

any

occurrence,

which

has

an

impacts in the care of patient.

1. ددهٌ ثداح يأ نع لٌصافتلا ءاطعإب مق/ رثؤٌ ضٌرملاب ةٌانعلا ىلع.

2.

OVR

Form

will

be

initiated

immediately

after

the

incident.

And submit it to your immediate

supervisor within the current work shift.

  • 2. دعب ارً وف ثداحلا رٌرقت ةرامتسا أبعت نأ بجٌ لمعلا ةرتف للاخ كسٌئر ىلإ ملست نأو ثداحلا.

3. The report will not be used

to

criticize

or

actions

of

involved.

blame

the

the

staff

  • 3. ءاقلإ وأ دقنل رٌرقتلا مدختسٌ لا نأ بجٌ

هنع ػلبملا مسقلا ىلع موللا

4. Corrective actions shall be taken to

minimize risk of injury and adverse

outcomes. Corrective action(s) shall be

documented.

  • 4. للقٌل ًحٌحصتلا ءارجلإا ذختٌ نأ بجٌ كلذل ةسكاعملا دودرلاو ررضلا رطخ نم. متٌ نأ بجٌ ًحٌحصتلا ءارجلإاو هقٌثوت/تلاجسلا ًف هلٌجست/ تادنتسملا.

5. The Occurrence report shall not be placed in the medical

record (Patient File) nor in

Employee File.

5. تلاجسلا ًف ثداحلا رٌرقت عضوٌ لا نأ بجٌ ةٌبطلا(ىضرملا تافلم) ؾظوملا ؾلم ًف وأ.

Confidentiality:

6

6. هٌّرسلا

  • 6.1 OVR reports will be handled in outmost confidentiality.

  • أ- ةمات ةٌرس ًف ملست نأ بجٌ ثداوحلا رٌراقت

    • 6.2 OVR should not be duplicated with exception of the Quality department.

    • ب- ةلماشلا ةدوجلا ةرادإ مسق ءانثتساب ثداحلا رٌرقت خسنٌ لا نأ بجٌ

      • 6.3 The information contained in the OVR form cannot and will not be used against any individual as basis for any disciplinary action.

ـج- يأ دض ثداحلا رٌرقت ةرامتسا ًف ةقثوملا تامولعملا مدختست نلو نكمٌ لا

ًبٌدأت ءارجإ يلأ صخش.

6.4 Hospital staff are NOT allowed to discuss the contents of an OVR or the events and circumstances relative to the occurrence either with patient, visitor or other members of the staff, unless clarifying facts under investigation with the proper authorities.

  • د- ثادحلأاو ىوتحملا اوشقانٌ نأ ىفشتسملا ًفظومل قحٌ لا

ًفظوم وأ رئازلا وأ ضٌرملا عم ءاوس ثداحلاب ةقلعتملا ؾورظلاو

ةسارد دنع قئاقحلا حٌضوت دنع لاإ ،نٌرخلآا ىفشتسملا ةلكشملا/نٌٌنعملا نٌلوئسملا عمو ثداحلا.

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

ـه- ثداحلا رٌرقت ًف ةماعلا لئاسملا ةشقانم نأ ضٌرملاب ةٌانعلا رٌوطتل مٌلعتلا وأ داشرلإا ضارؼلأ ةدشب اهعٌجشت متٌ.

6.7 Names of involved/concerned person should not be used. Use ID

number.

و -

هب ةقلعتملا صخشلا مسا مدختسٌ لا نأ بجٌ

طقف هفٌرعت مقر مدختسٌ لب ةٌضقلا.

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

ـه- ضارؼلأ ثداحلا رٌرقت ًف ةماعلا لئاسملا ةشقانم نأ متٌ ضٌرملاب ةٌانعلا رٌوطتل مٌلعتلا وأ داشرلإا ةدشب اهعٌجشت.

Occurrence Reporting

:ثداحلا نع غيلبتلا

Incident occurs ثداحلا عوقو
Incident occurs
ثداحلا عوقو
 
Awareness of the occurrence هثداحلا نع ػٌلبتلا Occurrence Variance Report Form is completed by the person

Awareness of the occurrence

 

هثداحلا نع ػٌلبتلا

Awareness of the occurrence هثداحلا نع ػٌلبتلا Occurrence Variance Report Form is completed by the person
 

Occurrence Variance Report Form is completed by the person witnessed/affected by the occurrence هثداحلا نم ررضت/دهش يذلا صخشلا لبق نم أبعت

 
 
Awareness of the occurrence هثداحلا نع ػٌلبتلا Occurrence Variance Report Form is completed by the person

Supervisor evaluates occurrence if it meets the Sentinel Event criteria

 
 

هعقوتم رٌؼ ةثداح تناك اذإام ؾرشملا مٌقٌ

Occurrence Reporting : ثداحلا نع غيلبتلا Incident occurs ثداحلا عوقو Awareness of the occurrence هثداحلا نع

Refer to Sentinel Event Committee

ثداوحلا ةنجل ػٌلبت

هئراطلا

Yes No Meets Sentinel Event Criteria
Yes
No
Meets
Sentinel
Event Criteria

رٌٌاعم قفاوت هئراطلا ةثداحلا

Supervisor/designee

carries out required

investigation

ةٌلوئسم ؾرشملا لمحتٌ

بولطملا قٌقحتلا

Physician informed completes the follow up as needed

بولطم وهامك هعباتملاب موقٌ ػلبملا بٌبطلا

No Other services/d ept. involved Yes
No
Other
services/d
ept.
involved
Yes

Take corrective action as needed and

document on the OVR form (Part I)

ىلع هلجسو جاتحم وه امك ًحٌحصتلا ءارجلإا ذختإ ثداحلا رٌرقت ةرامتسا

Refer to Sentinel Event Committee ثداوحلا ةنجل ػٌلبت هئراطلا Yes No Meets Sentinel Event Criteria رٌٌاعم
Refer to Sentinel Event Committee ثداوحلا ةنجل ػٌلبت هئراطلا Yes No Meets Sentinel Event Criteria رٌٌاعم
Refer to QIC/Supervisor of involved dept. and forward carbon copy to TQM ىلا هخسن لسرتو لووئسملا

Refer to QIC/Supervisor of involved dept. and forward carbon copy to TQM

ىلا هخسن لسرتو لووئسملا مسقلا نع هدوجلا رٌوطت ةنجل ؾرشم ػلب ةلماشلا ةدوجلا ةرادإ

Involved dept. supervisor/designee

investigate & document follow up

action/recommendation on OVR form (Part

I)

هتعباتم لجسٌو قٌقحتلاب موقٌ لووئسملا مسقلا ؾرشم

ءزجلا ًف ثداحلا رٌرقت ةرامتسإ ىلع هتاٌصوتو هءارجإو

Refer to QIC/Supervisor of involved dept. and forward carbon copy to TQM ىلا هخسن لسرتو لووئسملا

)ط(

QPS forwards quarterly reports to concerned areas, QMC & Safety Committee
QPS forwards
quarterly reports
to concerned
areas, QMC &
Safety Committee
Forward to QPS Dept. مسق ىلا لسرٌ ةدوجلا ةرادا ةلماشلا
Forward to
QPS Dept.
مسق ىلا لسرٌ
ةدوجلا ةرادا
ةلماشلا

Inform initiating dept.

of the action taken

لووئسملا مسقلا غلابا ذختملا ءارجلااب

QPS follows

up as

needed

ةرادا موقت هعباتملاب هدوجلا

ةمزلالا

TQM trends

all OVRs

ةدوجلا ةرادإ موقت

هٌجوتب ةلماشلا رٌراقت لك

ثداوحلا

Refer to QIC/Supervisor of involved dept. and forward carbon copy to TQM ىلا هخسن لسرتو لووئسملا
Refer to QIC/Supervisor of involved dept. and forward carbon copy to TQM ىلا هخسن لسرتو لووئسملا

Sentinel Event ةعقوتم رٌؽلا ةرٌطخلا ثداوحلا

Sentinel Event ةعقوتم رٌؽلا ةرٌطخلا ثداوحلا • An unexpected occurrence involving death, serious physical or psychological

An unexpected occurrence

involving death, serious

physical or psychological

injury to the patient

لثم ةعقوتملا رٌؼ ةرٌطخلا ثداوحلا ةٌسفنلاو ةٌدسجلا رارضلأاو توملا ىضرملل ةرٌطخلا.

Reportable Cases

اهنع ريرقتلا بجي تلااح

An unanticipated

death

Major permanent

loss of limb or

function, not

related to the

patients illness or

underlying

condition

Infant abduction

. عقوتملا رٌؼ ةافولا

  • وأ وضع نادقف سٌل ةٌدسج ةفٌظو

ضرمب ةقلاع هل .همٌونت وأ ضٌرملا

دولوم ؾاطتخا

Reportable Cases

اهنع رٌرقتلا بجٌ تلااح

suicidal attempt within the hospital premises.

Rape

Physical assault of a patient, staff or visitor

Infant discharge to the wrong family

لخاد راحتنلاا ةلواحم ىفشتسملا.

ءادتعلإا

ىلع يدسجلا ءادتعلإا وأ ؾظوملا وأ ضٌرملا رئازلا.

أطخلا ةلئاعلل لفط مٌلست.

Reportable Cases

Significant hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities

Surgery on the wrong patient or body part

Significant Medication errors (Overdose causing

death to patient.)

اهنع رٌرقتلا بجٌ تلااح

ضٌرملل ةٌلمع ءارجإ ةقطنملا ًف وأ ءًطاخلا ةئطاخلا.

ةحضاولا جلاعلا ءاطخأ ( ةببسملا ةدئازلا ةعرجلاك ضٌرملا ةافول).

Sentinel Event Reporting Process

ةعقوتم ريغلا ةرطخلا ثداوحلا نع غيلبتلا ةيلمع

   

1.

Immediate notification :رشابملا ػٌلبتلا .1

 
 

Departmental Quality Improvement Designee/Coordinator (QIC/Designee)

.ماسقلاا ةدوج نٌسحت قٌرف قسنم / لثمم

 
1. Immediate notification : رشابملا ػٌلبتلا .1 • Departmental Quality Improvement Designee/Coordinator (QIC/Designee) • . ماسقلاا
 

ّ

2. The QIC/D will notify ػ

: لبٌ

ؾوس ممصملا / ةدوجلا نٌسحت قٌرف .2

 

Head of the Department .مسقلا سٌئر -

 
 
1. Immediate notification : رشابملا ػٌلبتلا .1 • Departmental Quality Improvement Designee/Coordinator (QIC/Designee) • . ماسقلاا

3. The QID/C will call or bleep Quality Improvement Coordinator phone or in person.

قٌرط نع ةدوجلا نٌسحت ةقسنم غلابإب موقٌ قسنملا/ةدوجلا نٌسحت لثمم .ةرشابم اهتبطاخم وأ مقرلا بلط

4. Occurrence Report should be submitted to the Quality Improvement Coordinator

.ةدوجلا نٌسحت ةقسنم ىلإ ملسٌ نا بجٌ ثداحلا رٌرقت .4

4. Occurrence Report should be submitted to the Quality Improvement Coordinator . ةدوجلا نٌسحت ةقسنم ىلإ

5. Sentinel Event Coordinator will conduct an

investigation and interview the involved person and/or any witness of the event.

يأ وأ هنع ػلبملا صخشلا ةلباقمو قٌقحت لمعب ةدوجلا نٌسحت ةقسنم موقت ؾوس

ثداحلا ىلع دهاش

4. Occurrence Report should be submitted to the Quality Improvement Coordinator . ةدوجلا نٌسحت ةقسنم ىلإ

6. SE Coordinator will notify the Sentinel Event Committee and convene for a meeting.

رٌؽلا ةرٌطخلا ثداوحلا ةنجل ػٌلبتب ةدوجلا نٌسحت ةقسنم موقت ؾوس.6 .كلذل اعامتجا دقعتو هعقوتم

7. Root Cause Analysis will be initiated and facilitated.

بابسلأا لٌلحت.7 .مدقٌو حضوٌ ؾوس جئاتنلاو

7. Root Cause Analysis will be initiated and facilitated. بابسلأا لٌلحت .7 . مدقٌو حضوٌ ؾوس

8. Action plan will be designed as appropriate and implemented immediately.

.روفلا ىلع قبطتو ةٌولولأا بسح ىلع لمع ةطخ عضوت ؾوس.8

7. Root Cause Analysis will be initiated and facilitated. بابسلأا لٌلحت .7 . مدقٌو حضوٌ ؾوس

9. All investigation and conclusion documentation will be in the custody of the Quality Management Department and remained confidential.

ةدوجلا ةرادإ مسق ًف ةظوفحم لظت ؾوس ةقثوملا هجئاتنو قٌقحتلا لك .9

.ةٌرسب ً ةلماشلا

7. Root Cause Analysis will be initiated and facilitated. بابسلأا لٌلحت .7 . مدقٌو حضوٌ ؾوس

10. Follow up assessment will be conducted by SEC and the concerned

department within six (6) months of the event

عم ةعقوتم رٌؽلا ةرٌطخلا ثداوحلا ةنجل لبق نم لمكت ؾوس ةٌضقلا ةعباتم .10 .ثداحلا نم رهشأ ةتس للاخ ًنعملا مسقلا

Remember……. ركذت......

Avoid personal opinions

OVR is for reporting purposes only

It is not placed in the patient’s

medical record nor

to the employees file

كٌأر آدبإ بنجت ًصخشلا.

رٌرقت ةرامتسإ مدختست ػٌلبتلا ضارؼلأ ثداحلا طقف.

ًف رٌرقتلا عضوٌ لا وأ ًبطلا ضٌرملا لجس ؾظوملا ؾلم.

Remember……. ركذت......

The more you report the least errors be

committed,

and more

improvements

could be done.

ًف تعرسأ املك تللق املك ػٌلبتلا ءاطخلا ثودح ةبسن نم رٌثكلاو نأ نكمٌ نٌسحتلا لصحٌ.

If you don’t report,

and things be

discovered, then

you may expect

that you will be

reported.

See no incident, Hear no incident , Speak no

incident

  • - رٌرقت مدقت مل اذإ كلذ ؾاشتكإ متو

متٌ نا عقوت اهنٌح كنع رٌرقت عفر.

ىرأ ثداح لا , عمسأ ثداح لا, ملكتأ ثداح لا.

Your report counts because YOU COUNT!

- مهم كنلأ مهم كرٌرقت.