Occurrence Variance Report - Quality Management...

2012

Occurrence Variance Report Annual Report 2012

Patient Safety & Risk Management Unit KING KHALID UNIVERSITY HOSPITAL

2 OVR Annual Report 2012

TABLE OF CONTENTS

Introduction 3

Statistical Snapshot 2012 4

Classification of Occurrences 5

Reporting Departments 6

Reporter 7

OVR Categories 8

Clinical Practice/Procedure 10

Medication 11

Family/Visitor/Watcher 12

Staff/Employee 13

Equipment/Supplies 13

Safety 14

Fire/Security 14

Behavioral 15

Patient Care 16

Recommendations 17

References 17

Appendix – OVR Form 17


INTRODUCTION King Khalid University Hospital attaches the greatest of importance to the safety of patients,

employees, visitors and those who access our services and facilities. It is essential that

management and staff work together positively to achieve a situation consistent with the

provision of safe, high quality services to patients, where preventable incidents can be reduced

to a minimum.

All Occurrence Variances are encouraged to be reported at KKUH and as an organization it is

important there is a common understanding of what constitutes an untoward incident.

It is essential that following any occurrence variance or adverse event, an OVR is completed

and forwarded to Quality Management Department (QMD). The report is checked for

completeness, logged, forwarded to the designated QM Coordinator, sent to the Concerned

Department where appropriate action is taken relating to the event. On completion the OVR is

returned to Quality Management Department where the designated coordinator will check the

action and provide feedback as required. It is then scanned, returned to the Reporter, and any

concerned persons/department heads. In some instances an OVR may involve two departments

and a photocopy of the original OVR is made and sent to the respective department for follow-

up.

If a particular OVR requires further investigation, this is the responsibility of the Concerned

Department. For example a policy may need to be revised or developed, a procedure reviewed,

equipment changed, resources re-allocated.

If, on receiving an OVR it is classified as a Sentinel Event it is raised to the Director of QMD

who will initiate appropriate action and/or decide on an investigation using, for example, a

Root Cause Analysis approach.

As an organization there is a need to ensure all occurrence variances are reported. The Quality

Management Department is committed to encouraging staff to be open and honest in the

formal reporting of occurrence variance and near misses. To facilitate this we need to support

a philosophy that advocates a Just Culture, where the employee reporting an occurrence

variance feels confident that he/she has the support of Leadership. The overall outcome of an

occurrence variance is to improve systems not blame individuals.

The total number of Occurrence Variance Reports can provide valuable information and guide

our organization to improve safety practices. If staff fail to report due to concerns that

reporting will result in repercussions this will impact on achieving our objectives of providing

safe, high quality care and services to our clients. We urge all staff to report all occurrence

variance and promote positive safety outcomes at our hospital.

The Quality Management Department is looking forward to launching the (electronic) e-OVR

which will become effective in January 2013.


STATISTICAL SNAPSHOT 2012

During 2012 a total of 2362 OVR’s were reported to the Quality Management Department.

Compared to hospitals of similar size there is evidence of under-reporting.

2012-2011 COMPARISON

Upon investigating the reason for the deficit between 2011 and 2012 OVR reports, it was

found that during 2011 staff in OutPatient Clinics were encouraged to report missing medical

files along with staff transportation issues. While staff transportation appears to have

improved, the issue of missing patient medical files has not been resolved.

2011 2012

January 232 313

February 347 262

March 253 212

April 203 174

May 343 197

June 357 163

July 393 168

August 158 179

September 192 196

October 499 147

November 323 178

December 261 173

TOTAL: 3561 2362

Total OVR Received 2362

Closed OVR 1151 Pending OVR (as of Jan. 14, 2013) 959 OVR On-Hold in QMD 215 Incomplete OVR 5 Rejected OVR 32 Withdrawn by Reporter 1 With the Vice Dean 1


CLASSIFICATION OF OCCURRENCES

A Sentinel Event is defined as an unexpected occurrence involving the death or serious

physical or psychological injury, or risk thereof, including loss of limb or function, signaling

the need for immediate investigation and response.

A Major Event is defined as any occurrence which did not affect the outcome but for which a

recurrence carries a significant chance of a serious adverse outcome.

An Occurrence is defined as any event or circumstance that deviates from established

standards or care.

Near Miss is defined as any process variation which did not affect the outcome (by chance or

intervention), but for which a recurrence carries a significant chance of serious adverse

outcomes.

Sentinel Event Major Occurrence Near Miss

2012 0 51 2271 40


REPORTING DEPARTMENTS Reporting department describes the location of where the incident occurred and/or the

reporting person.

SN DEPARTMENT NO.

1 DEM 787

2 Ambulatory 286

3 Pediatric 245

4 Medicine 215

5 Surgery 193

6 Intensive Care Unit 149

7 OR 70

8 KFCC 69

9 Orthopedic 55

10 Oncology 47

11 OB-Gyne 40

12 Medical Records 28

13 Pharmacy 27

14 Business Center 26

15 Anesthesia 19

16 Radiology 19

17 Laboratory 17

18 Blood Bank 14

19 Bio-Medical & Engineering 11

20 Nursing 10

21 Psychiatry 10

22 Infection Control 5

23 QMD 5

24 Dental 3

25 Respiratory Therapy 3

26 Housekeeping 2

27 Rehabilitation 2

28 Medical Education 1

29 Medical Supply 1

30 Nutrition 1

31 Social Services 1

32 Transportation 1

Approximately 161,795 patients were seen in the Department of Emergency Services during

2012.


REPORTER Nursing staff are one of the largest employee groups and also the dominate reporting group.

REPORTER NO. Nurses 1944 Doctors 280 Technician 122 Head of Department 8 QMD 5 Housekeeping 2 Social Worker 1

PERSON INVOLVED Occurrence Variances can include any persons involved either as a pateint, employee, visitor or watcher. Patients, and those directly involved in health care are more likely to be persons involved in an occurrence variance.

PERSON INVOLVED NO. Others (see below for firther catergorisation) 904 Staff 672 Patient 666 Watcher 99 Visitor 21

OTHERS

Other involved categories include Medical Records, Medical Supplies, Biomedical and Engineering.

OTHERS – Related to No. Bed Management 181 Bio-medical & Eng’g 47 Dietary 9 Housekeeping 12 Housing 1 Infection Control 1 Information Management 12 Maintenance 110 Medical Files 297 Medical Supplies 117 Medication 23 Relatives 23 Safety & Security 42 Transportation 40


CATEGORIES OF OVR OVR’s have been classified into the following domains:

SUMMARY No. %

Clinical Practice/Procedure 444 19

Medication 221 9

Family/Visitor/Watcher 145 6

Staff/Employee 317 13

Equipment/Supplies 272 12

Safety 168 7

Fire/Security 157 7

Behavioral 110 5

Patient Care 524 22

Occupational 4 0

TOTAL 2362 100 Clinical Practice/Procedure refers to documentation, missing or unavailable medical records,

policy not available, Confidentiality and Procedures not followed.

Medication refers to any deviations in the usual practices involving prescribing, transcriibng,

preparation, dispensing, administration or storage and handling of medications.

Equipment and Supplies refers to improper handling of equipment, unavailability or shortage

of medical supplies, failure or malfunction of equipment, wrong equipment, or improper

storage. Unavailability of medical supplies, including medications, has prompted further

investigation to determine the root cause of this issue. 22 OVR’s were received during the 3rd

Quarter of 2012 relating to failure or malfunction of the pneumatic tube system. There were 6

OVR’s about computer malfunction.

Staff are encouraged to use the normal work flow to report maintenance issues. Unless a piece

of equipment was recklessly damaged, routine issues should not be reported as an occurrence

variance.


Occupational incidents are reported via the OVR system and usually involve the Occupational

Health department. As this is a newly established department and not fully operational, the

Infection Control department often deal with these occurrence variances. Needle stick injuries

have been the major staff related injury during 2012.

Monthly and Quarterly Occurrence Variance reports are submitted to each QMD Coordinator

responsible for their department. The quarterly report is forwarded to the respective

department. This provides the opportunity for departments to gauge their reported OVR’s on

an accumulative basis and determine an appropriate action plan. An Annual Data Base is also

reported to the Director of Qualtiy Management and Quality Management Coordinators.

Departmental Indicators have been developed and are being monitored by departments.

The following part of this report will focus on the high volume, high risk, error-prone OVR’s


SUB-CATEGORIES

Within each category are subcategories that provide more specific detail to the nature of the

OVR.

Clinical Practice/Procedure:

Examples of procedures not followed include blood product wastage, appointment issue,

wrong application of POP, Doctors’ orders not followed.

Accessibility to patient information via the patient medical file has been a challenging issue for

the Medcial Record Department and health care professioanls in patient care areas. Reports of

viodelnt or abusinve behanviour by patients has also been associated with unavailability of the

patient’s medical file. The statisics do not reflect the true nature of the medical record problem

due to underreporting. The impact of health care professionals not being able to access a

patient file, for example at the time of an appointment or during the admission process, can

have significant consquences on patient safety outcomes.

The Medical Record Department have been alerted to the high number of medical files not

available. Based on Policy & Procedures, the Medical Record department have requested all

medcial files be returned within 24 hours. Complaince has not been successful. Medical

Record staff routinely go to deparatments to track unreturned medical files.

During 2010 to 2011 inactive files were being scanned . Physicans can now access scanned

files in the clinic areas. In situations where a patient has more than one appointment on a day,

the Medical Record Department will note this on the computer system. They will try to ensure


the file goes to the first appointment. It is then the responsibility of the clinic to ensure the file

is forwarded on to the next clinic.

In some clinic areas there is access to the patients medicaiton history but this is not consistent

or convenient as the access may be in a location away from the Physician/Client actual

consultation. Access to the patients medication history in the absence of an unavailable medical

file is crucial in some situaiton, for example Oncology patients receiving chemotherapy.

The operational function of the Medical Record Department requires close studying to pin

point areas for improvement. The antiquated medical filing system is also in need of a major

overhaul. The new eSiHi system should provide a great relief for all patients and health care

professionals once established. The problem is significant and urgent critical action is requied

by Leadership to reovled this issue.

Medications

The medication management system is under the authority of the Pharmacy Department. Medication errors are often preventable and the Pharmacy Department has identified areas within the medication process that need to be improved. Under-reporting has been identified especially in relation to administration of medications. The main categories of OVR‘s relating to medication errors have been classified into the following table:

OTHERS 2 1st Q 2nd Q 3rd Q 4th Q TOTAL %

Medicine not Available 5 4 3 3 15 1

Mislabeling 0 3 0 0 3 0

Delayed Dispensing 2 1 0 4 7 0

IV Extravasation 0 2 2 4 8 0


Broken Narcotic Ampoule 3 2 0 1 6 0

Medicine On Hold 6 2 3 0 11 0

Unconsumed PCA 10 0 0 0 10 0

Prepared Meds not Given 0 0 0 10 10 0

The double checking process in Pharmacy has been raised as an areas of concern and staff

related issues such as Arabic literacy (cannot read English) and understaffing of pharmacists

have been identifed.

Medication availability is linked to actual medications on hand in the medical supply

department. The Inventory system for medication and a re-ordering process are examples of

areas for improvement. The purchasing process from vendors also may need to be considered

and establishment of secure contracts where supply is minimally an issue.

Broken Drill Bits

Previouysly there were few occurences relating to this issue but during 2012 a total of 11

broken drill bits were reported. This matter has been raised to the Director of Quality

Management.

OTHERS 1st Q 2nd Q 3rd Q 4th Q TOTAL

Broken Drill Bit 4 0 4 3 11

Family/Visitor/Watcher:

Unauthorised Watchers are often additional persons staying with the patient without

authorisation. On many occassions there is no transportation available to take the person

home. The Patient Relations Officer is usually called and gives approval for the person to

remain for the night. This however poses spacial problems and is not in accordance to hospital

policy.

Accommodation is not available within the hospital. Accommodation can be arranged via the

Social Work department but are usually reserved for out of town families who have a

hosptialised patient. It is also not possible for a unchaperoned female to travel alone.

OTHERS 3 1st Q 2nd Q 3rd Q 4th Q TOTAL %

Refused to take patient home 8 2 0 0 10 0

Unauthorized Watcher 30 17 14 9 70 3


Violent Behavior 6 1 7 3 17 1

Verbal Aggression 3 5 1 1 10 0

Staff/Employee

Staff transportation to housing had been an issue affecting nurses who complete night duty

and are awaiting transport back to their accommodation, or day duty nurses awaiting

transportation to work. This can impact on patient care as nurses may be late for duty and also

the wellbeing of staff.

Needle stick injuries involved 39 staff during 2012.

OTHERS 4 1st Q 2nd Q 3rd Q 4th Q TOTAL % Transportation Issue 9 3 43 4 59 2 Verbal Aggression 1 4 0 0 5 0 Misconduct/Behavior 6 9 6 9 30 1 No Response to Bleep 2 0 5 7 14 1 Porter Issue 8 4 5 2 19 1 Staff not Available 1 1 0 8 10 0 Miscommunication 0 2 2 0 4 0


Safety:

A total of 77 patient falls were record during 2012. Recommendations relating to patient falls

can be found in the Clincial Risk Assessment Report 2012 on the Qualtiy Management Website

(www.medicinequality.ksu.edu.sa).

1st Q 2nd Q 3rd Q 4th Q TOTAL %

Patient Fall 22 14 17 24 77 3

Patient Near Fall 1 1 2 1 5 0

Food Hygiene 5 1 1 2 9 0

Fire/Safety:

Occurrence variances have been reported relating to missing property. Personal items such as

mobile phones are comon items reported. The Security department have re-emphasised the

hospital policy encouraging patients and families not to bring valuables into the hospital.

Valuables can be stored at Admission department where access to lockable space is available.

In situations where patients abscond from the hospital, often there is a relationship with a

family situation or religious event. Patient may be permitted an Out On Pass if the Consultant

feels the patients health will not be compromised, but if he/she refuses, the patient will go

without authorization and this prompts the reporting of an OVR. When a patients absconds

from KKUH it is classified as a Code Yellow.

1st Q 2nd Q 3rd Q 4th Q TOTAL %

Absconded 18 19 39 30 106 4


Behavioral:

Patients who have been assessed as being able to be discharged may refuse to leave. The reason

may be related to no one at home available to provide care, or the family refuses to take them

home. This impacts on bed availablity at KKUH and Code Greens. Patients who refused to go

home, or to another hospital totaled 43 for 2012.

Violent and verbal behaviours were reported as a total of 47 incidents. Staff will receive

training on the management of aggressive behaviours in the future as a part of the Staff Self

Development Program. Behavioural issues have been associated with unavailablity of medical

records in some cases.

Others 8 1st Q 2nd Q 3rd Q 4th Q TOTAL %

Patient Refused to Go 15 9 13 6 43 2

Refused Medical Treatment 0 5 3 1 9 0


Patient Care:

Code Green refers to over-crowding in the Emergency Department. A total of 184 OVR’s were

submitted based on Code Greens. A Case Manager has been assigned but more are required to

improve the management of patient discharges and patient flow throughout the hospital.

Others 9 1st Q 2nd Q 3rd Q 4th Q TOTAL %

Bed Capacity Issue / Code

Green 29 45 53 57 184 8

Accidental Removal of

Tubes/Lines 9 11 2 0 22 1

Transfusion Reaction 1 0 2 3 6 0


RECOMMENDATIONS

It is essential that Senior Management consider the major issues affecting our hospital and put

in place strategies to facilate improvement. Each department is also encouraged to develop

quality improvement plans as applicable.

Currently we do not grade occurrance variances based on a risk matrix and future plans

include establishing a risk management process integrated into the OVR system.

A full copy of the Annual 2012 Occurrence Variance Report is available from QMD.

Please contact QMD if you would like to discuss this report further.

References

Occurrence Variance Report (OVR) Quality Management Department, King Khalid University Hospital: For the Period Oct. 2011-Oct. 2012.

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