Medical Center Health System.
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Medical Center Hospital System is committed to improving the quality and safety of patient
care through:
•
Identification and evaluation of errors, near misses or hazardous/unsafe conditions that
are a threat to patient safety or have the potential to result in patient harm.
•
Knowing about adverse events and potential adverse events enables the hospital to
analyze the events and put processes in place to prevent similar events from happening
in the future.
•
To foster a culture of safety and learning across the organization by openly discussing
patient safety at all levels.
MCHS uses an on-line tool that we call Patient Safety Event Reporting System. This is an on-
line reporting tool that allows you to select the type of an event and guides you through the
event identification process.
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• QR Code
•
MCHS Intranet Page - “Report a Patient Safety Event”
•
Desktop shortcut Icon -
•
PowerChart shortcut-
“Report Patient Safety Event”
A short “how to report” video can be accessed below:
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Reporting is essential to the identification and evaluation of errors for the purpose of
identifying root causes and trends which leads to improving processes which is essential to
reduce risk and prevent patient harm. All team members are required to participate in the
detection and reporting of any error, medication error, near miss, hazardous/unsafe condition,
process failure, injuries involving patients, visitors and staff or a sentinel event.
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Any happening not consistent with routine patient
care
•
Any event not consistent with normal operations
•
Any event that causes patient harm, or has the
potential to cause harm
•
A good catch or near miss- an event if it did occur
had the potential to cause harm
•
Patient complaints and grievances
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•
Enter as soon possible, so critical information is not
forgotten (with-in 24 hours)
•
Do not make copies of the
Patient Safety Event
•
Do not document in a chart that a
Patient Safety
Event
was submitted or request to submit a
Patient
Safety Event
•
Do not point fingers at other people or departments,
avoid hearsay, enter what you see
•
Only report the facts
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If a patient or patient’s representative threatens to get
a LAWYER- DO NOT PANIC!
•
Do Not engage in a conversation regarding their
statement or the appropriateness of their concerns
•
Contact Risk Management
•
Continue to provide care
Examples of reportable events:
•
Adverse Event – a patient safety event that resulted in harm to
a patient.
•
No-harm event- a patient safety event that reaches the patient
but does not cause harm. Near miss event (or “good catch”) –
a patient safety event that did not touch the patient.
•
Hazardous condition (or unsafe condition)- a circumstance,
other that the patient’s own disease process or condition, that
increases the probability of an adverse event.
•
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•
Unexpected Death
•
Permanent Harm
•
Severe temporary harm – A critical, potentially life-
threatening harm lasting for a limited time with no
permanent residual but requires transfer to a higher
level of care/monitoring for a prolonged period of time,
transfer to a higher level of care for a life-threatening
condition, or additional major surgery, procedure, or
treatment to resolve the condition.
•
Unanticipated death of a full-term infant.
•
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An elopement that leads to a patient death or
permanent harm.
•
Hemolytic transfusion reaction involving administration
of blood or blood products having major blood group
incompatibilities (ABO, Rh, other blood groups).
•
Invasive procedure, including surgery, on the wrong
patient, at the wrong site, or that is the wrong
(unintended) procedure.
•
Assault or rape.
•
Unintended retention of a foreign object in a patient
after an invasive procedure, including surgery.
•
Any intrapartum (related to the birth process) maternal
death.
•
Severe maternal morbidity (not primarily relates to the
natural course of the patient’s illness or underlying
condition) when it reaches a patient and results in
permanent harm or severe temporary harm.
•
All Falls
•
All AMA’s
•
Employee or other Staff Injuries
•
Diagnosis or treatment errors
**Medication errors, adverse drug events
**All new, new staged 3 and 4, and all unstageable
pressure ulcers acquired after admission/presentation
•
Surgical site infections
•
Equipment patient injuries
•
Patient injury associated with the use of contaminated
drugs
•
Lost Specimens
•
Diagnostic events leading to delay of care (lab,
Radiology, Respiratory)
•
ID/Documentation/Consents (
wrong MRN, incorrect consent)
•
Infection Control Issues
•
Environment
•
Patient Complaints/Grievances
•
Deviation from policy/protocol (education/training)
•
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Other reportable events
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Patient Safety Event Reporting System Policy MCH-4012
•
Personal Injury Occurrence and Emergency Care Policy MCH-
4029
•
NON-Punitive Reporting Policy MCH-4046
•
Chain of Command Issue Resolution Policy MCH- 1071
•
Sentinel Event/Patient Safety Event Policy MCH-4024
•
Safe Medical Device Act MCH-4025
•
Patient Complaint and Grievances MCH-2049
** Call 640-2293)
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:
Step 1- Enter
Date/Time of
Event
Step 2-
Select
Facility
Employee Injuries
Select Event
Type from
drop down
menu
Patient Event Reporting System
(screen shots on how to use)
Know: Patient First & Last Name
DOB, Gender, & FIN
Know Visitor: First & Last
Name, & Phone Number
Step 3- select
Department
Enter if another department
was involved with the event
Step 4
6- If yes, a window will open
To enter name/title
Click Submit
Step 5 enter
description
The Medical Center Health System (MCHS) emphasizes the importance of reporting patient safety events to improve the quality and safety of patient care. All team members are encouraged to report any deviation from routine care, events causing harm or potential harm, near misses, patient complaints, and hazardous conditions. Reporting enables the hospital to identify root causes, trends, and errors, leading to process improvements. MCHS provides an online reporting tool for easy submission of patient safety events, with guidelines on what to report and how to report them effectively.
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Presentation Transcript
Medical Center Health System Patient Safety Event Reporting: What you should report when entering a patient safety report: Any happening not consistent with routine patient care Any event not consistent with normal operations Any event that causes patient harm, or has the potential to cause harm A good catch or near miss- an event if it did occur had the potential to cause harm Patient complaints and grievances Medical Center Hospital System is committed to improving the quality and safety of patient care through: Identification and evaluation of errors, near misses or hazardous/unsafe conditions that are a threat to patient safety or have the potential to result in patient harm. Knowing about adverse events and potential adverse events enables the hospital to analyze the events and put processes in place to prevent similar events from happening in the future. To foster a culture of safety and learning across the organization by openly discussing patient safety at all levels. MCHS uses an on-line tool that we call Patient Safety Event Reporting System. This is an on- line reporting tool that allows you to select the type of an event and guides you through the event identification process. On the MCH home screen, click on Patient Safety Event shortcut and you will be taken to a screen with multiple icons, click on the icon which is the most appropriate, and enter the information about your report. You also may submit a Patient Safety Event through one of the following areas (all will give you an option to report Anonymously). QR Code Patient Safety Event Tips/Reminders: Enter as soon possible, so critical information is not forgotten (with-in 24 hours) Do not make copies of the Patient Safety Event Do not document in a chart that a Patient Safety Event was submitted or request to submit a Patient Safety Event Do not point fingers at other people or departments, avoid hearsay, enter what you see Only report the facts https://medicalcenter.performancehealth.app/solutions/incident-reporting MCHS Intranet Page - Report a Patient Safety Event Desktop shortcut Icon - Ensure patient safety- after any event that has occurred or hazardous condition has been identified, first and foremost staff should ensure the safety of the patient and notify the charge nurse and physician as appropriate. PowerChart shortcut- Report Patient Safety Event If a patient or patient s representative threatens to get a LAWYER- DO NOT PANIC! Do Not engage in a conversation regarding their statement or the appropriateness of their concerns Contact Risk Management Continue to provide care A short how to report video can be accessed below: https://www.loom.com/share/ddc03ff2085644bf8aae86bc4ab1a93a Why should you report patient safety events? Reporting is essential to the identification and evaluation of errors for the purpose of identifying root causes and trends which leads to improving processes which is essential to reduce risk and prevent patient harm. All team members are required to participate in the detection and reporting of any error, medication error, near miss, hazardous/unsafe condition, process failure, injuries involving patients, visitors and staff or a sentinel event.
Examples of reportable events: Adverse Event a patient safety event that resulted in harm to a patient. No-harm event- a patient safety event that reaches the patient but does not cause harm. Near miss event (or good catch ) a patient safety event that did not touch the patient. Hazardous condition (or unsafe condition)- a circumstance, other that the patient s own disease process or condition, that increases the probability of an adverse event. A sentinel event is a patient safety event (not primarily related to the natural course of the patient s illness or underlying condition) that reaches a patient and results in any of the following: Unexpected Death Permanent Harm Severe temporary harm A critical, potentially life- threatening harm lasting for a limited time with no permanent residual but requires transfer to a higher level of care/monitoring for a prolonged period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition. Unanticipated death of a full-term infant. Patient Suicide. (State Mandated) An elopement that leads to a patient death or permanent harm. Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups). Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure. Assault or rape. Unintended retention of a foreign object in a patient after an invasive procedure, including surgery. Any intrapartum (related to the birth process) maternal death. Severe maternal morbidity (not primarily relates to the natural course of the patient s illness or underlying condition) when it reaches a patient and results in permanent harm or severe temporary harm. All Falls All AMA s Employee or other Staff Injuries Diagnosis or treatment errors **Medication errors, adverse drug events **All new, new staged 3 and 4, and all unstageable pressure ulcers acquired after admission/presentation Surgical site infections Equipment patient injuries Patient injury associated with the use of contaminated drugs Lost Specimens Diagnostic events leading to delay of care (lab, Radiology, Respiratory) ID/Documentation/Consents (wrong MRN, incorrect consent) Infection Control Issues Environment Patient Complaints/Grievances Deviation from policy/protocol (education/training) Lost Items such as: glasses, dentures, hearing aides (see policy MCH-4031) use yellow bags/label bags Other reportable events Review the following policies to learn more about patient safety and reporting: Patient Safety Event Reporting System Policy MCH-4012 Personal Injury Occurrence and Emergency Care Policy MCH- 4029 NON-Punitive Reporting Policy MCH-4046 Chain of Command Issue Resolution Policy MCH- 1071 Sentinel Event/Patient Safety Event Policy MCH-4024 Safe Medical Device Act MCH-4025 Patient Complaint and Grievances MCH-2049 ** Call 640-2293) Contact Risk Management, Mary Gallegos at 432-640- 2487 or by email at mgallegos1@echd.org
Patient Event Reporting System (screen shots on how to use) Select Event Type from drop down menu Employee Injuries Step 2- Select Facility Step 1- Enter Date/Time of Event
Step 5 enter description Step 3- select Department 6- If yes, a window will open To enter name/title Enter if another department was involved with the event Step 4 Know: Patient First & Last Name DOB, Gender, & FIN Know Visitor: First & Last Name, & Phone Number Click Submit
