Presented by Natalie Woll, RN, BSN, Esq. Department of ...

1 OCCURRENCE. REPORTING. Presented by Natalie woll , RN, BSN, Esq. Department of Risk management What is NYPORTS? NYPORTS is an ADVERSE EVENT. reporting system and as such is not specifically designed to capture errors exclusively. Much of what is reportable reflects adverse events that are known to occur with certain frequency and in no way implies that an error has been made or particular blame is to be assigned. 2. Occurrence defined For the purpose of NYPORTS, an occurrence is an unintended adverse and undesirable development in an individual patient's condition, which occurs in a hospital. 3. A Hospital is accountable for reporting all occurrences that meet NYPORTS. reporting requirements, including those which occur in the inpatient and outpatient setting, Dialysis center, birthing facilities, etc (under the hospital's operating certificate).

2 4. What should be reported? Any instance involving patient harm Any unexpected occurrence involving a patient, visitor or employee Any sentinel event, or risk 5. Level 1. Reportable Adverse Events Require a root cause analysis Required to be reported into NYPORTS. within 24 hours or one business day of the date of awareness of the occurrence Reporting should be done when it is reasonable to initially assume that the adverse event was due to the course of care Don't wait 6. Level I - Reportable Adverse Events RCA Required NQF Definition Report as: Surgery or other invasive procedure performed on NYPORTS Code 911, with the wrong site appropriate subcode: DIG: Wrong Digit LEV: Wrong Level SID: Wrong Side SIT: Wrong Site Surgery or other invasive procedure performed on the wrong NYPORTS Code 911, patient subcode PAT.

3 Wrong surgical or other invasive procedure on a patient NYPORTS Code 911, subcode OTH. Unintended retention of a foreign object in a patient NYPORTS Code 913. after surgery or other invasive procedure Intraoperative or immediately post-operative/ NYPORTS Code 915, postprocedure death in a ASA Class 1 patient subcode SUR. Patient death or serious injury associated with the NYPORTS 938. use or function of a device in patient care in which the device is used or functions other than as intended Discharge or release of a patient/resident of any age, who is NYPORTS Code 962. unable to make decisions, to other than an authorized person 7. Level I - Reportable Adverse Events RCA Required NQF Definition Report as: Patient death or serious injury associated with patient NYPORTS Code 923.

4 Elopement Patient suicide, attempted suicide or self-harm that results NYPORTS Code 922. in serious injury, while being cared for in a healthcare facility Patient death or serious injury associated with a medication error NYPORTS Code 108. (perm patient harm) with Code 915, subcode RX. NYPORTS Code 109. (near-death) with Code 915, subcode RX. NYPORTS Code 110 (death). With Code 915, subcode RX. Maternal deaths or serious injury associated with labor and NYPORTS Code 915, delivery while being cared for in a healthcare setting subcode MAT. Death or serious injury of a neonate associated with labor NYPORTS Code 915, or delivery subcode NEO. Patient death or serious injury associated with a fall while NYPORTS Code 915, being cared for in a healthcare facility subcode FAL 8.

5 Level I - Reportable Adverse Events RCA Required NQF Definition Report as: Patient or staff death or serious injury associated with a burn NYPORTS Code 701. incurred from any source in the course of a patient care process in a healthcare facility Abduction of a patient of any age NYPORTS Code 961. Sexual abuse/assault on a patient or staff member within or on NYPORTS Code 963. the grounds of a healthcare facility Death or serious injury of a patient or staff member resulting NYPORTS Code 921. from a physical assault ( , battery) that occurs within or on the grounds of a healthcare facility NYPORTS Code 902- Specific patient transfers from D&TCs to hospital (D&TCs only). 9. New Sub Codes for Codes 915 & 913. Report along with Code 913.

6 Unintended retention of a foreign object in a patient Report along with Code 915 . NQF Definition Sub Code Patient death and/or serious injury Catheter CAT. NQF Definition Sub Drain DR. Code Drill Bit DB. Biologic Specimen BIO. Guidewire GW. Lab, Pathology, Radiology LPR. Instrument INS. Magnetic Resonance Imaging MRI. Lap Pad LP. Public Health Law 2805-1 PHL. Needle NE. Restraints, Bedrails RES. Other OTH. Sponge SP. Towel TO. Vaginal Sponge VS 10. Level 2. Reportable Events Required to be reported into NYPORTS. within 24 hours or one business day from the date of awareness of the occurrence No RCA required, unless specifically requested by DOH. 11. Level 2 - Reportable Adverse Events No RCA Required Code Description Code 914 Misadministration of radiation or radioactive material Code 931 Strike by hospital Staff Code 932 External disaster outside the control of the hospitals which affects Facility operation Code 933 Termination of any services vital to the continued safe operation of the hospital or to the health and safety of its patients and personnel Code 934 Poisoning occurring within the hospital Code 935 Hospital fire or other internal disaster disrupting patient care or causing harm to patients or staff Code 937 NYPORTS Code 937 - Malfunction of equipment during treatment or diagnosis or a defective product which has the potential for adversely

7 Affecting patient or hospital personnel 12. Why Report? To identify opportunities for improvement and to prevent recurrence by taking necessary action and driving improvements at the point of care. 13. Who reports occurrences? Any employee who is aware of an occurrence.. 14. How? Call Risk management ext. 3959. Complete Occurrence Form E-mail, Fax or Patient Safety Hotline 15. 16. Who determines reportability? 17. Over 90% of cases reported to Risk management are called in by Physicians Our greatest glory is not in never falling, but in rising every time we fall.. - Confucius 18. QUESTIONS? 19.