Download Incident - Karmanos Cancer Institute

Incident Reporting
&
Customer Complaint Management
2009
Yvonne Ciaravino
Barbara Ann Karmanos Cancer Center
April, 2009
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What is an “Incident”
• A situation or event that is out of the ordinary for
routine patient care or the hospitals normal
functioning.
• A situation or event that could harm or potentially
harm the health, life, comfort or property of:
– a patient (Patient Incident)
– an employee (Employee Incident)
– a visitor (Visitor Incident)
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What is an “Incident”
• Examples of incidents include:
– Adverse Drug Event:
• Adverse Drug Reaction: Unexpected, unintended, undesired or
excessive response to a medication
• Medication Variance: a preventable event that may cause or lead
to inappropriate medication use or patient harm
– Property Incident:
• Lost or damaged property belonging to visitors or KCC employees
• These type of incidents are reported directly to Security
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Patient Incidents (Patient Safety
Events)
• Situations or events that impact or nearly impact the patient
include:
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Medication events
Injury, falls, hospital acquired pressure ulcers
Missed, delayed or wrong treatment / procedure
Incidents involving a medical device: Where the device caused or almost
caused patient harm:
• Remove the device from service, leave the device plugged in to retain the
ability to retrieve an electronic history, tag it and report incident
immediately;
• Include identifying features of the device (serial number, model number,
name of equipment etc...) in the incident report
– Breech of patient confidentiality (HIPPA violations)
– Lost or damaged patient belongings
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Documenting a Patient Incident
• It is necessary to document patient incidents in the
medical record.
– Place an objective note in the patient’s chart documenting
the facts of the event, physician findings and treatment.
– DO NOT document that an incident report has been filed or
refer to the incident number.
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Employee Incidents (Employee
Safety Events)
• A situation or event occurring to an employee at Karmanos
Cancer Center or its premises, that is not consistent with the
employee’s routine work and may adversely affect or threaten to
affect, the health, life, comfort or property of an employee.
• Occurrences to be reported include:
– Slip, trips and falls
– Needle / sharps injuries
– Blood or body fluids to exposures
– Other incidents that result in potential Workers’ Disability claims or
which require a Michigan Occupational Safety & Health
Administration (MIOSHA) filing
– Incidents of workplace conflict and /or verbal, physical, emotional
abuse or harassment
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Employee Incidents
• Employee incidents must be reported to the department
manager and entered into the incident reporting system.
Incident entry can be done by the employee, manager or
witness to the incident.
• The Employee Injury/Illness Report must also completed per
MIOSHA regulations.
• The employee must report to the Emergency Department
(ED) or Occupational Health Services (OHS).
• The employee must take the Employee Injury/Illness Report
with them when they report for evaluation or treatment to the
ED or OHS.
• Human Resources must be informed of all employee
injuries.
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Reporting Incidents
• Employee Responsibility:
– Report the incident as soon as it happens or as soon as you
find out about it—after ensuring safety of the patient,
employee or visitor
– Report the incident to your supervisor or department manager
– Enter the incident into the web based incident reporting
system
– Immediately report work-related accidents, injuries, or near
miss events to your supervisor or department manager
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Incident Reporting and Follow-up
• Management Responsibility:
– If the “downtime” paper form was used to report an incident, enter
information into the web based incident reporting system and destroy
the paper form after entry is complete.
– Investigate the incident:
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Interview staff and determine additional factual information
Update the documentation in the incident
Add corrective actions
Adjust level of impact as appropriate
– Communicate incidents to other departments involved as indicated.
– Ensure that all events are reviewed and have follow-up
documentation within 14 days of event entry.
– Close all events within 30 days of event entry with the exception of
medication events and events with severity level of “F” or higher.
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Incident Reporting and Follow-up
• Management Responsibility:
– Notify the Department Director, Administrator, Quality
Department and Risk Management regarding any situation
which may have the potential for significant negative
outcomes, serious patient injury or adverse media attention.
– Notify the Safety Officer regarding unsafe or hazardous
conditions.
– Report any employee lost time to Human Resources within 24
hours of incident.
– Identify, implement, educate and document actions taken to
lessen likelihood of incident recurring.
– Encourage incident identification and entry by staff.
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Incident Reporting and Follow-up
• Other Department Responsibilities:
– Pharmacy:
• Pharmacy reviews and closes all medication related events.
• If a drug is reported to the FDA Medical Products Reporting
Program (MEDWATCH), pharmacy will document this in the
“follow up” section of the incident report.
– Quality & Regulatory Affairs:
• Reviews all incidents.
• Closes all events (excluding medication events) with severity
level of “F” or higher.
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Complaint Reporting
• Patient, Family and Visitor Complaints:
– Karmanos Cancer Center encourages patients, families
and visitors to freely express their grievances,
complaints, concerns, dissatisfactions and inquiries
through established channels without being subject to
coercion, discrimination, reprisal, or unreasonable
interruption of care, treatment and services.
– We welcome feedback from our patients, families and
visitors and are attentive to all concerns shared.
– Feedback provides us with the opportunity to learn about
our customer’s experience and make improvements if
necessary to exceed their expectations.
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Complaint Reporting
• Patient, Family and Visitor Complaints—definitions:
– Medical Grievance: Any complaint (written or verbal) the
subject of which is the quality of care received, or premature
discharge, or release of patient, including complaints against
physicians.
– Concern / Dissatisfaction: Any expression of concern or
dissatisfaction (written or verbal) with a service or facility
provided by the Karmanos Cancer Center, that is resolved to
the satisfaction of the complainant, at the point of complaint
or at the point of service.
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Complaint Reporting
• Patient, Family and Visitor Complaints—definitions:
– Grievance: Any expression of dissatisfaction (complaint)
related to an occurrence within a Karmanos Cancer Center
facility, which is of such severity that it is not able to be
resolved to the satisfaction of the complainant at point of
service. Examples include:
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Delays in service
Patient care
Facility policy or procedure
Cost / billing / insurance
Lack of respect / privacy
Safety of patient environment
Environmental concerns
Equipment
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Complaint Reporting
• Patient, Family and Visitor Complaints—timeliness:
– Whenever possible, employees will address and attempt to resolve
issues immediately, at the point of service.
– If the complaints cannot be resolved at point of service to the
satisfaction of the patient, family or visitor, it will be entered into the
Incident and Complaint Management System.
– The complaint will then be managed as a formal grievance by the
Customer Service Department.
– Management and the Customer Service Department will attempt to
contact the patient/family within 2 business days.
– All formal grievances are brought to closure within 30 days of receipt.
– A summary of our investigational findings is provided to the
complainant in a formal letter format within the 30 day period.
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