Event Reporting Policy

Subject: Event Reporting
Effective Date: February 2008
Review Date: October 2007, November 2011, October 2016

Purpose

To define events involving unsafe actions or conditions which create potential or actual harm to patients, visitors, or staff, faculty and students. This policy provides guidelines for correct notification, documentation, reporting, and evaluation of such events.

General Policy

The reporting and documentation of events furnishes essential data used to assist department managers, responsible administrators, UW and Health Sciences Risk Management and the School of Dentistry Quality Improvement programs to follow-up, analyze and resolve of events to reduce future adverse outcomes and/or unsafe conditions.

Implementation

A. Reporting Responsibility

Any faculty, resident, student or staff who is aware of an unsafe condition or who is involved in or aware of a harm event (or an event that could have resulted in harm) has a responsibility to document the incident and report it to their supervisor.

1. Timeliness – All types of events should be reported within 24 hours of the event by School of Dentistry faculty, residents, students and staff.

Harm: Any event resulting in harm should be immediately communicated to the Clinic Manager or appropriate supervisor of that area. If the event resulted in a hospital admission or patient death or neurological damage, call Health Sciences Risk Management immediately (598-6303) and the Associate Dean of Clinic Services (616-5931).

2. Confidentiality – All reporting and analysis of patient events or events is confidential under Washington state law as part of the School of Dentistry’s Coordinated Quality Improvement Plan. Anonymous reporting of events is allowed.

3. Provide Immediate Medical Care: For all exposures or aspirations, and accidents, the involved staff must do the following:

a. Notify attending faculty and facilitates appropriate care and treatment for the patient, visitor or staff member.

b. First Aid – Provide First Aid if necessary. Use first aid kit located in all clinics and labs. Contact health care provider OR if necessary, go to UWMC Emergency Room (normal fees apply.) Students may contact Hall Health at (206) 685-1011.

c. Exposure/Incident Hotline – Call the hotline during school hours to report the event.

Between 8:00am—5:00pm: CALL Exposure Hotline at 206‐351‐2268.
After 5:00pm: GO directly to UWMC Emergency Room.
CPD Employees: Contact your Clinic Supervisor and attending faculty member, then call the Exposure/Incident Hotline at 206‐351‐2268.

The Health & Safety staff member assigned to the hotline will go directly to the scene of the event to coordinate follow-up with the patient and Employee health.

B. Event Definitions

Reportable Event: A suspected or actual variation in a health care delivery process where the patient/visitor is affected.

Potential Event: (Also known as a “close call” or “near miss” or “nice catch”): An error or variation in a health care delivery process that is discovered before the patient/visitor is affected.

Medication Event: Any event that could cause or lead to a patient receiving inappropriate drug therapy, failure to receive appropriate drug therapy, or any unexpected outcome related to drug therapy, is considered a Medication Event. Medication events include, but are not limited to, Adverse Drug Reactions.

Adverse Drug Reaction: An adverse drug reaction (ADR) is any unintended, undesired, and unavoidable noxious effect of agents administered to patients for diagnostic, prophylactic, or therapeutic indications.

Sentinel Event: An unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function.

The phrase, “or risk thereof” includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Event has resulted in an unanticipated death or an actual or unanticipated major permanent loss of function not related to the natural course of the patient’s illness or underlying condition.

Health Sciences Risk Management (598-6303) and the Associate Dean of Clinic Services (616-5931) must be contacted immediately by telephone when a sentinel event occurs.

C. Documentation

Events involving patients are documented separately from events involving students, staff or faculty

1. Events involving Patients or Visitors

a. Medical/Dental Record:

A factual description of the event, the patient’s response, and treatment provided should be documented in the patient’s medical or dental record if applicable.

Note: Do not reference the patient event report or any conversations with Health Sciences Risk Management in the dental record.

b. Patient Event Form
Any unsafe condition or event involving a patient or visitor is reported using the Patient Event Form (RequestManager) (see Appendix A)

c. Risk Master:
The patient event is documented in the Risk Master system. This includes analysis of the patient record, input from faculty, student, and staff input from those involved in the event, a synopsis of all communication with the patient, and the resolution.

2. Events involving Students, Staff or Faculty

Online Accident Reporting System (OARS)
Events involving a staff member or student injury are reported online via the OARS (requires UWNetID)
(See Appendix B for sample OARS Report)

D. Analysis, Reporting and System Improvements

1. The Clinic Manager or supervising manager evaluates the event, recording their interventions on the Patient Event Form or in the OARS report as appropriate.

2. The Attending Faculty who was supervising has the primary responsibility for communicating unanticipated outcomes to the patient and family. (Refer to the Disclosure of Unanticipated Outcomes policy.)

3. The manager or supervisor of a “Care Area” reviews all of their event reports within 72 hours of the event (excluding weekends, holidays and/or extenuating circumstances.)

a. OARS Report follow-up process

Once the event is submitted the OARS system will notify the listed supervisor for follow-up.
The supervisor will meet with all involved parties to identify preventive measures and root cause.
Any findings will be documented in the final submission of the OARS report.
The supervisor will determine if any other follow-up is necessary, including but not limited to, change in work or care area process, training of the individual, or conferring with H&S team for input.

b. Patient Event Report Follow-up process

Once the patient event is submitted, it is entered into Risk Master by Patient Relations for tracking and trending purposes.
Patient Relations will follow-up with faculty and staff to identify potential system-based contributing factors; address any individual education, competency, or behavior issues; and to provide support as appropriate.
The Manager of Patient Services reviews all incident reports and enters them into Risk Master for tracking and trending as part of the School of Dentistry’s Coordinated Quality Improvement Plan.
Event reports are forwarded to the Director of Clinic Operations and to relevant faculty for follow-up as needed.
Health Sciences Risk Management is notified of events entered into Risk Master.
The Associate Dean for Clinics will provide quality, patient safety, and risk committees with quarterly reports.
Oversight of event management is provided by the Clinical Services Committee, the CQIP Operations Committee and the CQIP Oversight Committee to determine appropriate organizational responses to system issues