Occurrence Variance Report - Quality Management …

1 2012 Occurrence Variance Report Annual Report 2012 Patient Safety & Risk Management Unit KING KHALID UNIVERSITY HOSPITAL 2 OVR Annual Report 2012 TABLE OF CONTENTS Introduction 3 Statistical Snapshot 2012 4 Classification of Occurrences 5 Reporting Departments 6 Reporter 7 OVR Categories 8 Clinical Practice/Procedure 10 Medication 11 Family/Visitor/Watcher 12 Staff/Employee 13 Equipment/Supplies 13 Safety 14 Fire/Security 14 Behavioral 15 Patient Care 16 Recommendations 17 References 17 Appendix OVR Form 17 3 OVR Annual Report 2012 INTRODUCTION King Khalid University Hospital attaches the greatest of importance to the safety of patients, employees, visitors and those who access our services and facilities.

2 It is essential that Management and staff work together positively to achieve a situation consistent with the provision of safe, high Quality services to patients, where preventable incidents can be reduced to a minimum. All Occurrence Variances are encouraged to be reported at KKUH and as an organization it is important there is a common understanding of what constitutes an untoward incident. It is essential that following any Occurrence Variance or adverse event, an OVR is completed and forwarded to Quality Management Department (QMD).

3 The Report is checked for completeness, logged, forwarded to the designated QM Coordinator, sent to the Concerned Department where appropriate action is taken relating to the event. On completion the OVR is returned to Quality Management Department where the designated coordinator will check the action and provide feedback as required. It is then scanned, returned to the Reporter, and any concerned persons/department heads. In some instances an OVR may involve two departments and a photocopy of the original OVR is made and sent to the respective department for follow-up.

4 If a particular OVR requires further investigation, this is the responsibility of the Concerned Department. For example a policy may need to be revised or developed, a procedure reviewed, equipment changed, resources re-allocated. If, on receiving an OVR it is classified as a sentinel Event it is raised to the Director of QMD who will initiate appropriate action and/or decide on an investigation using, for example, a Root Cause Analysis approach. As an organization there is a need to ensure all Occurrence variances are reported.

5 The Quality Management Department is committed to encouraging staff to be open and honest in the formal reporting of Occurrence Variance and near misses. To facilitate this we need to support a philosophy that advocates a Just Culture, where the employee reporting an Occurrence Variance feels confident that he/she has the support of Leadership. The overall outcome of an Occurrence Variance is to improve systems not blame individuals. The total number of Occurrence Variance Reports can provide valuable information and guide our organization to improve safety practices.

6 If staff fail to Report due to concerns that reporting will result in repercussions this will impact on achieving our objectives of providing safe, high Quality care and services to our clients. We urge all staff to Report all Occurrence Variance and promote positive safety outcomes at our hospital. The Quality Management Department is looking forward to launching the (electronic) e-OVR which will become effective in January 2013. 4 OVR Annual Report 2012 STATISTICAL SNAPSHOT 2012 During 2012 a total of 2362 OVR s were reported to the Quality Management Department.

7 Compared to hospitals of similar size there is evidence of under-reporting. 2012-2011 COMPARISON Upon investigating the reason for the deficit between 2011 and 2012 OVR reports, it was found that during 2011 staff in OutPatient Clinics were encouraged to Report missing medical files along with staff transportation issues. While staff transportation appears to have improved, the issue of missing patient medical files has not been resolved. 2011 2012 January 232 313 February 347 262 March 253 212 April 203 174 May 343 197 June 357 163 July 393 168 August 158 179 September 192 196 October 499 147 November 323 178 December 261 173 TOTAL: 3561 2362 Total OVR Received 2362 Closed OVR 1151 Pending OVR (as of Jan.)

8 14, 2013) 959 OVR On-Hold in QMD 215 Incomplete OVR 5 Rejected OVR 32 Withdrawn by Reporter 1 With the Vice Dean 1 5 OVR Annual Report 2012 CLASSIFICATION OF OCCURRENCES A sentinel Event is defined as an unexpected Occurrence involving the death or serious physical or psychological injury, or risk thereof, including loss of limb or function, signaling the need for immediate investigation and response. A Major Event is defined as any Occurrence which did not affect the outcome but for which a recurrence carries a significant chance of a serious adverse outcome.

9 An Occurrence is defined as any event or circumstance that deviates from established standards or care. Near Miss is defined as any process variation which did not affect the outcome (by chance or intervention), but for which a recurrence carries a significant chance of serious adverse outcomes. sentinel Event Major Occurrence Near Miss 2012 0 51 2271 40 6 OVR Annual Report 2012 REPORTING DEPARTMENTS Reporting department describes the location of where the incident occurred and/or the reporting person.

10 SN DEPARTMENT NO. 1 DEM 787 2 Ambulatory 286 3 Pediatric 245 4 Medicine 215 5 Surgery 193 6 Intensive Care Unit 149 7 OR 70 8 KFCC 69 9 Orthopedic 55 10 Oncology 47 11 OB-Gyne 40 12 Medical Records 28 13 Pharmacy 27 14 Business Center 26 15 Anesthesia 19 16 Radiology 19 17 Laboratory 17 18 Blood Bank 14 19 Bio-Medical & Engineering 11 20 Nursing 10 21 Psychiatry 10 22 Infection Control 5 23 QMD 5 24 Dental 3 25 Respiratory Therapy 3 26 Housekeeping 2 27 Rehabilitation 2 28 Medical Education 1 29 Medical Supply 1 30 Nutrition 1 31 Social Services 1 32 Transportation 1