Transcript DMC Incident Reporting DMC Incident Reporting Employee education competency module DMC Environment of Care Department Detroit Medical Center© February, 2010 1 of 30

DMC Incident Reporting
DMC Incident Reporting
Employee education competency module
DMC Environment of Care Department
Detroit Medical Center©
February, 2010
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DMC Incident Reporting
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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Incident Reporting – Process Issues
Most events or errors happen because of process
issues:
 Many “little” failures lead to a “bigger” event
 Rarely a “person” failure
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Incident Reporting – Blame-Free Environment
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.
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Types of Safety Incidents
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.
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Incident Reporting
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.
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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 incident
o Physician findings
o Treatment
 Do not document that an incident report has been filed or refer
to the incident number.
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DMC Incident Reporting
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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Types of Safety Incidents
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.
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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.
5. Answer every question to the best of your ability.
See policy 1 CLN 017 Safe Medical Device Act.
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Reviewable Event Recording
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).
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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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Employee Incidents
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.
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Reporting Employee Incidents
 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.
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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.
7. Answer every question to the best of your ability.
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When Should You Report An Incident?
As soon as it happens or as soon as you find out
about it:
- See 1 CLN 026 Incident Reporting Policy.
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Incident Reporting – Staff Responsibilities
 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.
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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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Incident Reporting – Other Department Responsibilities
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.
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Patient, Family and Visitor Complaints
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.
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Patient, Family and Visitor Complaints
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).
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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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Compliance Hotline – 1.888.484.9200
 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.
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Quality of Care
 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
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Course Summary
 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 webbased 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.
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Thank You
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.
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