Sentinel Events & OVR (lecture)
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The document outlines the definitions, procedures, and responsibilities related to occurrence variance reports (OVR) and sentinel events in a healthcare setting. It explains types of adverse and sentinel events, the importance of reporting near misses, and the protocol for investigating and responding to such incidents. Additionally, it emphasizes confidentiality and the non-punitive nature of reports to improve patient safety and quality of care.
Sentinel Events & OVR (lecture)
- 1. OVR & OVR & SENTINEL SENTINEL EVENTS EVENTS TQM Department Lecture By Dr. Aqeel Ahmed Khan QM Coordinator-ACH
- 2. 2 CONTENTS:CONTENTS: Definitions of termsDefinitions of terms • OCCOURANCEOCCOURANCE • OVROVR • ADVERSE EVENTADVERSE EVENT • VARIENCEVARIENCE • NEAR MISS (& why it should beNEAR MISS (& why it should be reported)reported) • SENTINEL EVENTSSENTINEL EVENTS • “ ““ “ (Types)(Types) • “ ““ “ (policy)(policy)
- 3. 3 CONTENTS:CONTENTS: • SENTINEL EVENTS (Procedure)SENTINEL EVENTS (Procedure) • How to deal with sentinel/adverseHow to deal with sentinel/adverse eventevent • Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR • Who should report /responsibilitiesWho should report /responsibilities (Employee, attending physician, immediate(Employee, attending physician, immediate supervisor, TQM department, safety officer)supervisor, TQM department, safety officer) • OVR policyOVR policy • OVR form restrictionsOVR form restrictions • OVR form sampleOVR form sample
- 4. 4 OCCURRENCEOCCURRENCE • An event which is not consistent with routineAn event which is not consistent with routine patient care or with the routine operation ofpatient care or with the routine operation of the facility & which adversely affects orthe facility & which adversely affects or threatens the health or life of patient, visitor,threatens the health or life of patient, visitor, employee, student or volunteer whichemployee, student or volunteer which involves loss or damage to personal orinvolves loss or damage to personal or hospital property. An occurrence alsohospital property. An occurrence also includes any event that might other wiseincludes any event that might other wise result in any other adverse situation or aresult in any other adverse situation or a claim against the organization.claim against the organization.
- 5. 5 OCCURRENCEOCCURRENCE VARIANCE REPORTVARIANCE REPORT (OVR) DEFINITION:(OVR) DEFINITION: • An internal form which is issued toAn internal form which is issued to document the details of thedocument the details of the occurrence / event and theoccurrence / event and the investigation of an occurrence andinvestigation of an occurrence and the corrective actions taken.the corrective actions taken.
- 6. 6 ADVERSE EVENTADVERSE EVENT • It is an unwanted, undesirable andIt is an unwanted, undesirable and usually unanticipated event such asusually unanticipated event such as death of patient, an employee, or adeath of patient, an employee, or a visitor in a health care organization.visitor in a health care organization. Occurrences such as patient falls areOccurrences such as patient falls are also considered adverse events ifalso considered adverse events if there is no permanent effect on thethere is no permanent effect on the patient.patient.
- 7. 7 VARIANCEVARIANCE • Is the difference in results obtainedIs the difference in results obtained in measuring the samein measuring the same phenomenon more than once.phenomenon more than once. Excessive variation frequently leadsExcessive variation frequently leads to waste and loss; such as theto waste and loss; such as the occurrence of undesirable patientoccurrence of undesirable patient health outcomes and increased costhealth outcomes and increased cost of health services.of health services.
- 8. 8 • An event or situation that could haveAn event or situation that could have resulted in an accident, injury orresulted in an accident, injury or illness but did not either by chance orillness but did not either by chance or through timely intervention.through timely intervention. NEAR MISSNEAR MISS
- 9. 9 Why should reportWhy should report NEAR MISSNEAR MISS Sentinel events Adverse events Near misses, other accidents and occurrences • They haveThey have the samethe same root causes,root causes, as sentinelas sentinel events, soevents, so they shouldthey should also bealso be reportedreported
- 10. 10 SENTINEL EVENTSENTINEL EVENT (DEFINITION)(DEFINITION) • Any unexpected occurrenceAny unexpected occurrence involving death, serious physical orinvolving death, serious physical or psychological injury or the riskpsychological injury or the risk thereof, and any event that mightthereof, and any event that might cause embarrassment or risk to thecause embarrassment or risk to the hospital with potential legalhospital with potential legal implications and / or media inquiresimplications and / or media inquires or coverage.or coverage.
- 11. 11 SENTINEL EVENTSENTINEL EVENT • The phrase “or the risk thereof”The phrase “or the risk thereof” includes any process variation forincludes any process variation for which a recurrence would carry awhich a recurrence would carry a significant chance of a serioussignificant chance of a serious adverse outcome. Such events areadverse outcome. Such events are called “sentinel” because theycalled “sentinel” because they signal the need for immediatesignal the need for immediate investigation and response.investigation and response.
- 12. 12 SENTINEL EVENTSENTINEL EVENT (TYPES)(TYPES) • Serious injury includes but is notSerious injury includes but is not limited to:limited to: – Unexplained or unexpected deathsUnexplained or unexpected deaths or permanent loss of limb or functionor permanent loss of limb or function that is not a result of the patient’sthat is not a result of the patient’s medical condition.medical condition.
- 13. 13 – Surgery on theSurgery on the wrong patientwrong patient – Surgery on wrongSurgery on wrong body partsbody parts – Wrong procedureWrong procedure SurgerySurgery SENTINEL EVENTSENTINEL EVENT (TYPES)(TYPES)
- 14. 14 SENTINEL EVENTSENTINEL EVENT – Rape of a patient, staff or visitorRape of a patient, staff or visitor – Infant abductionInfant abduction – Unexpected death of full-term infantUnexpected death of full-term infant – Child discharge to the wrong familyChild discharge to the wrong family – Hemolytic blood transfusionHemolytic blood transfusion – Patient suicide in the hospitalPatient suicide in the hospital
- 15. 15 – Retained instrument or spongeRetained instrument or sponge – Intravascular gas embolismIntravascular gas embolism – Maternal deathMaternal death – Medication Errors leading to death orMedication Errors leading to death or major morbiditymajor morbidity – Patient’s fall resulting death orPatient’s fall resulting death or severe dysfunction of body partsevere dysfunction of body part SENTINEL EVENTSENTINEL EVENT
- 16. 16 SENTINEL EVENTSENTINEL EVENT POLICYPOLICY –All sentinel events requireAll sentinel events require immediate investigation andimmediate investigation and appropriate response by theappropriate response by the corresponding committees. Allcorresponding committees. All events should have an occurrenceevents should have an occurrence generated report (OVR)generated report (OVR)
- 17. 17 SENTINEL EVENTSENTINEL EVENT PROCEDUREPROCEDURE 1.1. Identification of a Sentinel EventIdentification of a Sentinel Event 2.2. Appointment of Task ForceAppointment of Task Force 3.3. Completion of Root Cause AnalysisCompletion of Root Cause Analysis 4.4. Committee ReportCommittee Report 5.5. Any report or documents generatedAny report or documents generated by the Task Force are Confidentialby the Task Force are Confidential and Privilegedand Privileged
- 18. 18 SENTINEL EVENT Immediate Containment Action Reporting and Notification Investigation and Review Action Plan & Monitoring How to deal with a SentinelHow to deal with a Sentinel Event/Adverse EventEvent/Adverse Event Unit heads / dept chairs AP, Unit heads / dept chairs + Customer Service Unit heads / dept chairs, AP, Team + Risk Management Office Unit heads / dept chairs, SQD + MQIO Persons accountable
- 19. 19 PURPOSE OF OVRPURPOSE OF OVR • To provide a systematic hospital –To provide a systematic hospital – wide identification mechanism aswide identification mechanism as quality improvement tool for earlyquality improvement tool for early detection and prevention ofdetection and prevention of problems which have (or may have)problems which have (or may have) an adverse patient outcome andan adverse patient outcome and represent a potential hazard torepresent a potential hazard to patients, visitors, volunteers,patients, visitors, volunteers, students or employees.students or employees.
- 20. 20 PURPOSE OF OVRPURPOSE OF OVR • To plan and implement correctiveTo plan and implement corrective measures through identification bymeasures through identification by root cause analysis.root cause analysis. • To analyze the data and developTo analyze the data and develop preventive measures periodically.preventive measures periodically. • To help identify areas needingTo help identify areas needing improvement or recognitionimprovement or recognition
- 21. 21 WHEN TO USE OVR:WHEN TO USE OVR: • Injury to visitors or volunteersInjury to visitors or volunteers while on the hospital premiseswhile on the hospital premises • Any incident which is notAny incident which is not consistent to routine patientconsistent to routine patient carecare
- 22. 22 WHEN TO USE OVR:WHEN TO USE OVR: • Occurrences not consistent withOccurrences not consistent with routine operation of facility and /orroutine operation of facility and /or adversely affects, threatens theadversely affects, threatens the health or life of patient, visitor,health or life of patient, visitor, employee, student or volunteer.employee, student or volunteer. • Loss or damage to personal orLoss or damage to personal or hospital property.hospital property.
- 24. 24 RESPONSIBILITIES:RESPONSIBILITIES: • The employee who witnesses orThe employee who witnesses or discoversdiscovers –Immediate notification ofImmediate notification of attending physician in case ofattending physician in case of injury and Immediate Supervisorinjury and Immediate Supervisor
- 25. 25 RESPONSIBILITIES:RESPONSIBILITIES: • Attending PhysicianAttending Physician –Complete and document his/herComplete and document his/her action (s) on the OVR formaction (s) on the OVR form immediately upon carrying out hisimmediately upon carrying out his examination and/or the requiredexamination and/or the required treatment or care.treatment or care.
- 26. 26 RESPONSIBILITIES:RESPONSIBILITIES: • Immediate SupervisorsImmediate Supervisors –Consultation with the involvedConsultation with the involved employee (s)employee (s) –Resolution of problems shouldResolution of problems should take place when possible withintake place when possible within and between departmentsand between departments
- 27. 27 RESPONSIBILITIES:RESPONSIBILITIES: • Immediate SupervisorsImmediate Supervisors –Ensuring that all employees areEnsuring that all employees are aware of OVR Reporting System;aware of OVR Reporting System; how to report and the steps byhow to report and the steps by steps procedure on how tosteps procedure on how to complete the form.complete the form. –Conduct immediate action andConduct immediate action and follow up after the incident occursfollow up after the incident occurs
- 28. 28 RESPONSIBILITIES:RESPONSIBILITIES: • Immediate SupervisorsImmediate Supervisors –Document on the OVR the actionsDocument on the OVR the actions taken and/or any correctivetaken and/or any corrective measures, taken to prevent themeasures, taken to prevent the recurrence of the eventrecurrence of the event –Evaluates incident if meetsEvaluates incident if meets sentinel event criteriasentinel event criteria
- 29. 29 RESPONSIBILITIES:RESPONSIBILITIES: • Immediate SupervisorsImmediate Supervisors – Forward the completed (original) OVRForward the completed (original) OVR report form to the Total Qualityreport form to the Total Quality Management office within 72 hours (3Management office within 72 hours (3 days) of the occurrencedays) of the occurrence – Conduct any further investigation andConduct any further investigation and document, report investigateddocument, report investigated findings upon request of the Hospitalfindings upon request of the Hospital Administration the QualityAdministration the Quality Management CommitteeManagement Committee
- 30. 30 RESPONSIBILITIES:RESPONSIBILITIES: •The Total QualityThe Total Quality Management DepartmentManagement Department –Monitoring all OVR for followMonitoring all OVR for follow upup –Trending and preparing aTrending and preparing a monthly summarymonthly summary
- 31. 31 RESPONSIBILITIES:RESPONSIBILITIES: •The Total QualityThe Total Quality Management DepartmentManagement Department –Submitting a quarterly reportSubmitting a quarterly report to the Quality Managementto the Quality Management Committee for discussion andCommittee for discussion and what action can be done in thewhat action can be done in the future to avoid recurrence.future to avoid recurrence. –Upkeep the fileUpkeep the file
- 32. 32 RESPONSIBILITIES:RESPONSIBILITIES: • The Safety OfficerThe Safety Officer – Investigate all safety related incidentsInvestigate all safety related incidents – Organize a review team of selectedOrganize a review team of selected Safety Committee members toSafety Committee members to investigate critical safety relatedinvestigate critical safety related occurrencesoccurrences – Document the results of investigationDocument the results of investigation and corrective action taken on theand corrective action taken on the OVR form and forwards it to the TQM.OVR form and forwards it to the TQM.
- 33. 33 OVR POLICYOVR POLICY • Report the details of any occurrence,Report the details of any occurrence, which has an impacts in the care ofwhich has an impacts in the care of patient.patient. • OVR Form will be initiated immediatelyOVR Form will be initiated immediately after the incident. And submit it to yourafter the incident. And submit it to your immediate supervisor within the currentimmediate supervisor within the current work shift.work shift. • All sections of the OVR form must beAll sections of the OVR form must be completed and submitted to thecompleted and submitted to the immediate supervisor within the currentimmediate supervisor within the current work shift.work shift.
- 34. 34 OVR POLICYOVR POLICY • The report will not be used toThe report will not be used to criticize or blame the actions of thecriticize or blame the actions of the staff involved.staff involved. • Corrective actions shall be taken toCorrective actions shall be taken to minimize risk of injury and adverseminimize risk of injury and adverse outcomes. Corrective action (s) shalloutcomes. Corrective action (s) shall be documented.be documented. • The Occurrence report shall not beThe Occurrence report shall not be placed in the medical record (Patientplaced in the medical record (Patient File) nor in Employee File.File) nor in Employee File.
- 35. 35 OVR POLICYOVR POLICY • Confidentiality:Confidentiality: All OVR shall be handled andAll OVR shall be handled and maintained in a confidentialmaintained in a confidential manner with access to suchmanner with access to such documentation restricted todocumentation restricted to authorized individuals.authorized individuals. OVR shall not be duplicated, withOVR shall not be duplicated, with exception of the QM department,exception of the QM department, when deemed necessary.when deemed necessary.
- 36. 36 OVR POLICYOVR POLICY The information contained in theThe information contained in the OVR form cannot and shall not beOVR form cannot and shall not be used against any individual as theused against any individual as the sole basis for disciplinary action.sole basis for disciplinary action. The involved person’s MRN #The involved person’s MRN # instead of his/her name will beinstead of his/her name will be used on the OVR form.used on the OVR form.
- 37. 37 OVR POLICYOVR POLICY Hospital staff is not at liberty to discussHospital staff is not at liberty to discuss the content of an OVR or the eventsthe content of an OVR or the events and circumstances relative to theand circumstances relative to the occurrence either with patient, visitoroccurrence either with patient, visitor or other members of the staff, unlessor other members of the staff, unless clarifying facts under investigationclarifying facts under investigation with the proper authorities.with the proper authorities. Discussion of general issues on OVR forDiscussion of general issues on OVR for instructional or educational purposesinstructional or educational purposes with view to improving patient care iswith view to improving patient care is however strongly encouraged.however strongly encouraged.
- 38. 38 The OVR form shouldThe OVR form should not:not: Be PhotocopiedBe Photocopied Be Placed in Medical RecordBe Placed in Medical Record Be DiscussedBe Discussed Be given Personal OpinionsBe given Personal Opinions
- 39. 39 Do Not:Do Not: Use the names ofUse the names of involved/concerned person.involved/concerned person. Use the content of the OVRUse the content of the OVR against any individual foragainst any individual for disciplinary action.disciplinary action. Divulge any informationDivulge any information written on the OVR form towritten on the OVR form to unconcerned individuals &unconcerned individuals & media.media.
- 40. 40 EQUIPMENTS /EQUIPMENTS / FORMS:FORMS: OccurrenceOccurrence VarianceVariance Report FormReport Form
- 41. 41 OVR FORMOVR FORM DATE & TIME OF INCIDENT: _______________________ WARD/ROOM/DEPARTMENT: ______________________ DIAGNOSIS: _____________________________________ STATUS (CHECK ONE): ( ) IN-PATIENT ( ) OUT-PATIENT ( ) VISITOR ( ) EMPLOYEE ( ) OTHER (SPECIFY): _____________________ MEDICAL RECORD NUMBER: _____________ AGE: _____________SEX: __________________ NATIONALITY: __________________________ DATE & TIME RECORD INITIATED: _________________________________________ __________________________________________ _ INTRAVENOUS RELATED ( ) Central Line ( ) Contrast Media Reaction ( ) Extravasate ( ) Occluded ( ) Precipitate ( ) Site Red/Swollen ( ) Tubing Leak ( ) Expired Fluid ( ) Additive Related ( ) Transfusion Reaction ( ) Other __________________ PROCEDURE VARIANCE ( ) Delay ( ) Missing Files/Notes ( ) Performed on Wrong Site ( ) Consent ( ) Patient Identification ( ) Wrong Patient ( ) Wrong Procedure ( ) Lost/Spoiled Specimen ( ) No Response ( ) Wrong File ( ) Procedure Cancellation ( ) Notes in Wrong File ( ) Inadequate/Inappropriate entry ( ) No Label/Addressograph ( ) Other ___________________________ BEHAVIOR ( ) DAMA ( ) Absconded ( ) Dissatisfied with Care ( ) Patient Behaivior ( ) Family/Visitor Behaivior ( ) Staff Behaivior ( ) Borrowed Medical Record Card ( ) Non-Compliance HAZARD/SAFETY ( ) Burn ( ) Chemical Spill ( ) Electrical Shock ( ) Fire ( ) Gas ( ) Hazardous Waste ( ) Radiation Exposure ( ) Chemical Splash ( ) Water Spill ( ) Other________________________ SECURITY VARIANCE ( ) Damage/Loss of Property ( ) Drug Count Variance ( ) Drug Keys ( ) Prescription Alteration ( ) Security Problem ( ) Suicide Attempt ( ) Other ___________________ EQUIPMENT/SUPPLIES ( ) Electrical Problem ( ) Equipment Not Working ( ) Mechanical Problem ( ) Operator Not Qualified ( ) Wrong Equipment ( ) Missing Equipment ( ) Not Available ( ) Out of Stock ( ) Other ___________________ ARAR CENTRAL HOSPITAL PART A – ADDRESSOGRAPH OCCURRENCE VARIANCE REPORT (NOT PART OF THE MEDICAL RECORD) OCCURRENCE TYPE
- 42. 42 PART B 2-1 – DESCRIBE THE OCCURRENCE (STATE THE FACTS) FACTUAL DESCRIPTION …………………………………………………………………………………………………………………………………………….…..… ………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………….………… …………………………………………………………………………………………………………………………………..……………… Reported By: Name: ………….………………………..…..…. ID No. ………….… Dept. …………... Position………….…….. Witness By: Name: ………………………………………….. ID No. ……….…… Dept. …….……... Position………………... IMMEDIATE ACTION: (PART B 2-2) Physician Notified: ( ) YES ( ) NO ( ) NOT APPLICABLE Did MD see patient: ( ) YES ( ) NO If yes, investigation/s done: ( ) X-ray ( ) Suture ( ) Blood work ( ) Medication Assessment/Diagnosis: (PART B 3-1) ………………………………………………………………………………………………………………………….………………..……… …………………………………………………………………………………………………………………………………….……..……… SEVERITY CODE (CHECK ONE) PART B 3-2 ( ) Minor - no injury or minor treatment (i.e. abrasion; no increased length of stay; no increased level of care) ( ) Moderate - increased length of stay; increased level of care ( ) Major - temporary or permanent lessening of body functions ( ) Sentinel - catastrophic; death or major permanent loss of function ( ) Near Miss - potentially severe outcome IMMEDIATE ACTION (PART C) Action taken by initiating department Action taken by the responding department ……………………………………………………………..………… …………………………………………………………………..…… …………………………………………………………………..…… ……………………………………………………………..………… ……………………………………………………………..………… ……………………………………………………………..………… …………………………………………………………..…………… …………………………………………………………………… …………………………………………………….……………… ………………………………………………….………………… ………………………………………………….………………… ………………………………………………….………………… ………………………………………………….………………… ………………………………………………….………………… Head of Department: Date: Head of Department: Date: TQM OFFICE COMMENT: PART D ………………………………………………………………………………………………………………………………………………… ………………………………………………………………………………………………………………………………………………… OVR FORM (PAGE 2)
- 43. 43 SUMMARY OFSUMMARY OF LECTURE:LECTURE:• OCCOURANCEOCCOURANCE • OVR (Definition)OVR (Definition) • ADVERSE EVENTADVERSE EVENT • VARIENCEVARIENCE • NEAR MISS (& Why it should be reported)NEAR MISS (& Why it should be reported) • SENTINEL EVENTS (Definition)SENTINEL EVENTS (Definition) • “ ““ “ (Types)(Types) • “ ““ “ (policy)(policy) • “ ““ “ (Procedure)(Procedure)
- 44. 44 SUMMARY OFSUMMARY OF LECTURE:LECTURE:• How to deal with sentinel/adverse eventHow to deal with sentinel/adverse event • Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR • Who should report /responsibilitiesWho should report /responsibilities (Employee, attending physician, immediate(Employee, attending physician, immediate supervisor, TQM department, safety officer)supervisor, TQM department, safety officer) • OVR policyOVR policy • OVR form restrictionsOVR form restrictions • OVR form sampleOVR form sample
- 45. 45