RISK MANAGEMENT: OPPORTUNITY FOR IMPROVEMENT AND INCIDENT REPORTS *

Effective Date: 
Sat, 06/01/2002
Reviewed: 
Wed, 06/06/2018
Revised: 
Wed, 06/06/2018
Policy: 

A critical part of the Student Health Services Quality Management Program is Risk Management. One important part of risk management is the identification, reporting and analysis of incidents. The definition of a reportable incident includes any clinical or non-clinical occurrence that is not consistent with the routine care or operation of the organization. Incidents may involve students, visitors or employees.  At the SHS these events are recorded in categories: Opportunities for Improvement and Incidents.  An incident includes any event that could result in unanticipated injury, harm or loss to anyone working or visiting the SHC.

The definition of an adverse incident includes:

1) Unexpected occurrence during a health care encounter involving patient death or serious physical or psychological injury or illness, including loss of limb or function, not related to the natural course of the patient’s illness or underlying condition.
2) Any process variation for which a recurrence carries a significant chance of serious or negative adverse outcome.
3) Events such as actual breaches in medical care, administrative procedures, or other events resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service for a patient.
4) All events involving reactions to drugs and materials.
5) Circumstances or events that could have resulted in an accident, illness or injury but did not, either by chance or through timely intervention (i.e., near-miss events).

Reporting and studying these events is a critical part of quality assurance, quality improvement and risk mitigation.  The SHS leadership encourages staff to report any incident, near-miss events or opportunity of improvement for analysis to prevent the potential of a true adverse incident.

Laboratory and Pharmacy Departments complete any additional documentation as per their respective regulatory agency requirements. (See linked policies)

All incidents are logged and reviewed by appropriate manager or supervisor.
All adverse incidents are analyzed to identify the basic or causal factors underlying the incident and potential improvements in processes or systems, if any exist, to reduce the likelihood of such incidents in the future as well as improvements that reduce the likelihood of future adverse incidents, when indicated.

It is the policy of the Student Health Services that any event for which an incident would carry significant risk of a serious adverse outcome needs to be reported as an Opportunity for Improvement or an Incident Report.

Opportunity for Improvement reports may be escalated to an Incident Report at the discretion of the Medical Director and the Risk Management Committee.

Examples of Opportunities for Improvement include the following (Use Form HC 411):

  • Campus Health Events
  • Documentation error (charting)
  • Lab or imaging results not received in a timely manner
  • Quality of care issue raised by patient
  • Quality of care issue raised by staff member
  • Dissatisfied or angry patient
  • Patient care concern
  • System or process needing improvement

Exception:  Hospital Transfers - Voluntary or Involuntary including 5150 (use HC 738 Primary Care Hospital Transfer Review form or CAPS/Psychiatry Hospital Transfer Review form)

Examples of Incident Reports include the following (submit via RL Solutions link below):

  • Aberrant behavior
  • Adverse outcome
  • Circumstance or event that could have resulted in an adverse events (near-miss events)
  • Confidentiality breach (actual or potential) including identification errors
  • Clinical care issues
  • Crimes that occur within the facility including physical assault (may use Workplace violence)
  • Deaths that occur at the SHS
  • Diagnosis or Treatment errors
  • Emergency procedures (resuscitation, 911 calls) (use Other)
  • Employee misconduct
  • Exposure or potential exposure to hazard (Needle stick injury, chemicals, blood borne pathogens, unsafe equipment)
  • Facilities issues
  • Formal grievances filed by patients (use Clinical care or Other)
  • Infection Control or Prevention
  • Injuries or falls that occurs in the facility
  • Laboratory error, accident, or unexpected event resulting in significant negative impact on patient care or safety of patients or staff.  Could include reference lab issue, interface issue, wrong order, mislabeled specimen
  • Litigation involving the organization and its staff and health care professionals (use Operational risk)
  • Malfunction of any medical device or equipment that impacts patient care (use Equipment/Medical Supplies)
  • Medical or imaging procedure performed on the wrong body part
  • Medical or imaging procedure performed on the wrong patient
  • Medication and vaccine errors
  • Operational risk
  • Privacy violations (use Confidentiality Errors)
  • Reactions to drugs and materials
  • Refrigerator/temperature monitoring system malfunction or error (use Equipment/Medical Supplies)
  • Reputational risk (use Operational Risk or Other)
  • Safety and security lapses or breaches
  • Sentinel event at Student Health Services (use Clinical Care or Diagnosis/Treatment or Other)
  • Scanning error-significant (use Other)
  • Suicide attempts - (Serious  Suicide Attempt by Existing Client) (Use Clinical Care Issue)
  • Workplace violence

 

Procedure: 

All staff are responsible for completing a report of any event for which occurrence or reoccurrence could result in harm to a patient or to health center staff or events in which procedures or processes did not meet established standards of care.

Reports are generated using form HC:411 (Opportunity for Improvement) or the RL Solution online incident reporting system (see link below) anytime there is an unexpected opportunity or incident at the Student Health Center involving patient, staff or visitors.

Reports will use the Patient's SID but will be converted to PNC internal ID Number when entered in RL solutions.  Staff will be identified by initials and job or role.  If necessary a fictitious date of birth can be entered into the system.

1. The Assistant to the Executive Director receives and logs the reports.

2. Reports are forwarded to the Medical Director and appropriate Student Health Services staff.

3. Reports are investigated by the appropriate supervisor.

4. Completed reports are reviewed and closed by the Medical Director.

In more sensitive situations an appropriate subcommittee is convened to investigate the event (see Case Reviews). Staff who submit a formal grievance will be notified in writing that the grievance has been received and will be formally investigated by the appropriate SHS manager. The outcome of the investigation will be reported to the Executive Director and governing body within 14 business days. The individual submitting the grievance will be provided a formal response in a timely manner within 30 days of receipt of the grievance.  If more than 30 days is required to finalize a response the individual submitting the grievance will be notified in writing of the expected completion time. The SHC will adhere to all laws and regulations as it pertains to reporting formal grievances.

A summary of the event and recommended actions for mitigation is composed by the Medical Director and submitted to the Assistant to the Executive Director.

Examples of risk mitigation activity recommendations may include but are not limited to staff education, EMR template revisions, systems changes and procedural modifications.

Individual staff members involved in incidents are provided specific feedback as appropriate.

The report is a privileged document.  It is not a part of a medical record and is not available for use in litigation.  To protect this privilege the report may not be copied and may not be referred to in the medical record.

Opportunities for improvement, incident reports and other risk mitigation activities are summarized quarterly and reported to the Quality Management Committee for review and discussion.

As appropriate summaries of important events and lessons learned are shared with staff.

In some cases recommendations for procedural change will be discussed by the QM committee and staff.

The SHS has access to and actively involves campus counsel and the Office of Risk Services for assistance in evaluating and responding to these events and for all risk management and liability issues.

 

 

Key Points: 

 A critical part of Quality of Care at the Student Health Center is the identification and evaluation of incidents and events which result in or could result in harm to a patient or staff member.

A system is in place for capturing a record of these events and studying them.

The Medical Director is responsible for this element of the risk management plan.

Reports of these events are summarized and presented to the QM committee quarterly.