Reportable event summary review form - Office of the ...€¦ · Reportable event summary review...
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Reportable event summary review form Public and private health facilities June 2014 For completion by all public and private health facilities for all reportable events when: • an alternative form of review to a Root Cause Analysis (RCA) is conducted • no review is conducted • an RCA is commenced and then stopped. 1. Name and address of health facility at which the reportable event occurred 2. Date reportable event occurred 3. Reportable event identification number (allocated by facility) 4. What was the reportable event that occurred? Select reportable event type and patient outcome Maternal death Serious maternal morbidity Death Permanent injury Neurological damage Further surgery (a) maternal death or serious maternal morbidity associated with labour or delivery (b) the death of a person associated with the incorrect management of the person’s medication (c) the death of a person, or neurological damage suffered by a person, associated with an intravascular gas embolism (d) the wrong procedure being performed on a person, or a procedure being performed on the wrong part of a person’s body, resulting in the death of the person or an injury being suffered by the person (e) the retention of an instrument, or other material, in a person’s body during surgery that requires further surgery to remedy the retention (f) the death of a person, or an injury suffered by a person, associated with a haemolytic blood transfusion reaction resulting from the wrong blood type being used for the person during a blood transfusion (g) the suspected suicide of a person receiving inpatient health care (h) the suspected suicide of a person with a mental illness who is under the care of a provider of mental health services while residing in the community (i) any other death of a person, or an injury suffered by a person, that was not reasonably expected to be an outcome of the health service provided to the person Notes 1. Reportable events are prescribed under section 29 of the Hospital and Health Boards Regulation 2012 2. Reference to an injury is a reference to an injury that is likely to be permanent 3. For definition of mental illness, see the Mental Health Act 2000, section 12 5. Describe the reportable event that occurred Provide a factual account of the reportable event including the patient’s gender and age and the nature of the health service provided to the patient
Transcript of Reportable event summary review form - Office of the ...€¦ · Reportable event summary review...
Reportable event summary review form
Public and private health facilities June 2014
For completion by all public and private health facilities for all reportable events when: • an alternative form of review to a Root Cause Analysis (RCA) is conducted• no review is conducted• an RCA is commenced and then stopped.
1. Name and address ofhealth facility at whichthe reportable eventoccurred
2. Date reportable eventoccurred
3. Reportable eventidentificationnumber(allocated by facility)
4. What was the reportable event that occurred?Select reportable event type and patient outcome
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(a) maternal death or serious maternal morbidity associated with labour or delivery
(b) the death of a person associated with the incorrect management of the person’s medication
(c) the death of a person, or neurological damage suffered by a person, associated with an intravascular gas embolism
(d) the wrong procedure being performed on a person, or a procedure being performed on the wrong part of a person’s body, resulting in the death of the person or an injury being suffered by the person
(e) the retention of an instrument, or other material, in a person’s body during surgery that requires further surgery to remedy the retention
(f) the death of a person, or an injury suffered by a person, associated with a haemolytic blood transfusion reaction resulting from the wrong blood type being used for the person during a blood transfusion
(g) the suspected suicide of a person receiving inpatient health care
(h) the suspected suicide of a person with a mental illness who is under the care of a provider of mental health services while residing in the community
(i) any other death of a person, or an injury suffered by a person, that was not reasonably expected to be an outcome of the health service provided to the person
Notes 1. Reportable events are prescribed under section 29 of the Hospital and Health Boards Regulation 20122. Reference to an injury is a reference to an injury that is likely to be permanent3. For definition of mental illness, see the Mental Health Act 2000, section 12
5. Describe the reportable event that occurredProvide a factual account of the reportable event including the patient’s gender and age and the nature of the health serviceprovided to the patient
6. Was a RCA commenced and then stopped? Yes No
7. If yes, please specifylegislative basis RCAstopped
Section 102 of the Hospital and Health Boards Act 2011 (stopped by RCA team)
Section 103 of the Hospital and Health Boards Act 2011 (stopped by RCA commissioning authority)
8. Was a review conducted of the reportable event? Yes Go to Q10 No
9. If no review was conducted, please specify the reason/s for this and go to Q16.
10. Type of review conducted (please select one only)
Internal investigation Human Error and Patient Safety analysis Clinical review
Incident analysis Morbidity and mortality committee case review Other (please specify)
11. Date review commenced Date review completed
12. What were the factors that contributed to the reportable event?Select from the categories below (developed by the Australian Institute of Health and Welfare) and describe the circumstances
Contributing factor Summary description (please specify)
Patient assessment
Staff factors
Patient factors
Equipment
Work environment
Information/documentation
Communication
Rules/policies/procedures
Coordination
Other contributing factor/s (please specify)
13. Were any improvement measures/recommendations identified to reduce the likelihoodof, or prevent, a recurrence of a similar event?
Yes Go to Q14
No Go to Q15
14. If yes, please provide details of each of the improvement measures/recommendations, including the timeframes forimplementation
Improvement measures/recommendations Timeframes
15. If no improvement measures/recommendations were identified, please specify the reason/s
16. This form was completed by:
Name
Position
Organisation
Phone Email
Please send completed reportable event summary review forms to the OHO by: • Email: [email protected] (preferred method)• Post: PO Box 13281, George Street, Brisbane 4003
Completed reportable event summary review forms are to be submitted to the OHO within 15 business days of: • the relevant authority authorising the completed review of the reportable event; or• the decision is made not to conduct a review of a reportable event; or• the decision is made to stop an RCA that has been commenced.
You may attach supporting documentation (e.g. copy of Human Error and Patient Safety analysis).
