Common Formats Aggregate Report Hospital

Transcription

1 Common Formats Aggregate Report Hospital HEALTHCARE EVENT REPORTING FORM (HERF), PATIENT INFORMATION FORM (PIF), AND SUMMARY OF INITIAL REPORT (SIR) CLASSIFICATION OF EVENT OR UNSAFE CONDITION TYPE Event 3,856 1, ,157 Incident 2, Harm 1, No harm 1, Can't tell about harm Near miss (close call) 1, Unsafe condition CATEGORY Blood or Blood Product Device or Medical/Surgical Supply, including Health Information Technology (HIT) Fall Healthcare-associated Infection Medication or Other Substance 1, Perinatal Pressure Ulcer Surgery or Anesthesia Venous Thromboembolism Other Page 1 of 10

2 CLASSIFICATION OF EVENT OR UNSAFE NQF CLASSIFICATION Serious Reportable Events Surgical or Other Invasive Procedure events Procedure performed on the wrong site Procedure performed on the wrong patient Wrong procedure performed on the patient Unintended retention of a foreign object in a patient after surgical or other procedure Intraoperative or immediately postoperative/postprocedure death in an ASA Class 1 patient Product or device event Patient death or serious injury associated with the use of contaminated drugs, devices, or biologics Patient death or serious injury associated with the use or function of a device other than as intended Patient death or serious injury associated with intravascular air embolism Patient protection event Discharge or release of patient who is unable to make decisions to unauthorized person Patient death or serious injury associated with patient leaving the facility without permission Patient suicide, attempted suicide, or self-harm that results in serious injury Page 2 of 10

3 CLASSIFICATION OF EVENT OR UNSAFE NQF CLASSIFICATION Serious Reportable Events (continued) Care management event Patient death or serious injury associated with a medication error Patient death or serious injury associated with unsafe administration of a blood product Maternal death or serious injury associated with labor or delivery in a low-risk pregnancy Death or serious injury of a neonate associated with labor or delivery in a low-risk pregnancy Patient death or serious injury associated with a fall while being cared for in a healthcare setting Any Stage 3, Stage 4 and unstageable pressure ulcers acquired after admission/presentation to a healthcare setting Artificial insemination with the wrong donor sperm or wrong egg Patient death or serious injury resulting from loss of irreplaceable biological specimen Patient death or serious injury resulting from failure to follow up or communicate laboratory, pathology or radiology test results Environmental event Patient or staff death or serious injury associated with an electric shock Any incident in which systems designated for oxygen or other gas to be delivered to a patient contains no gas, the wrong gas or is contaminated by toxic substances Patient or staff death or serious injury associated with a burn incurred from any source Patient death or serious injury associated with the use of physical restraints or bedrails Page 3 of 10

4 CLASSIFICATION OF EVENT OR UNSAFE NQF CLASSIFICATION Serious Reportable Events (continued) Radiologic events Death or serious injury of a patient or staff associated with the introduction of a metallic object into the MRI area Not a Serious Reportable Event 3,826 1, ,158 Can t tell whether a Serious Reportable Event CIRCUMSTANCES OF EVENT OR UNSAFE CONDITION LOCATION OF EVENT OR UNSAFE CONDITION Inpatient general care area (e.g., medical/surgical unit) 1, Special care area (e.g., ICU, CCU, NICU) Labor and delivery Operating room or procedure area, including PACU, recovery area Radiology/imaging department Pharmacy Laboratory, including pathology department, blood bank Emergency department Other area within the facility Outpatient care area Outside area (i.e., grounds of facility) Other Can t tell location Page 4 of 10

5 CIRCUMSTANCES OF EVENT OR UNSAFE Incidents and near misses submitted 3,856 1, ,157 TIME OF EVENT DISCOVERY Day of week Sunday Monday Tuesday Wednesday Thursday Friday Saturday Can t tell day of discovery Time of day AM 1, PM 2, Can t tell time of discovery CONTRIBUTING FACTORS Contributing factors known by time of SIR Event with at least one contributing factor identified 2,850 1, Environment Culture of safety, management Physical surroundings (e.g., lighting, noise) Staff qualifications Competence (e.g., qualifications, experience) Training Supervision/support Clinical supervision Managerial supervision Policies, procedures, and clinical protocols Presence of policies Clarity of policies Page 5 of 10

6 CIRCUMSTANCES OF EVENT OR UNSAFE Incidents and near misses submitted 3,856 1, ,157 CONTRIBUTING FACTORS (continued) Contributing factors known by time of SIR Event with at least one contributing factor identified 2,850 1, Data Availability Accuracy Legibility Communication Supervisor to staff Among staff or team members Staff to patient (or family) Human factors Fatigue Stress Inattention Cognitive factors Health issues Other Other No contributing factors identified Can t tell about contributing factors HANDOVER (HANDOFF) Event was associated with handover (handoff) Event was not associated with handover (handoff) 3,292 1, ,017 Can t tell about handover (handoff) Page 6 of 10

7 CIRCUMSTANCES OF EVENT OR UNSAFE Incidents and near misses submitted 3,856 1, ,157 Event that reached patient 2, PREVENTABILITY OF INCIDENT Almost certainly could have been prevented Likely could have been prevented Likely could not have been prevented Almost certainly could not have been prevented Provider does not make this determination by policy Can t tell about preventability Event that did not reach patient 1, WHY NEAR-MISS DID NOT REACH PATIENT Fail-safe and/or safeguard worked effectively Practitioner or staff who made the error noticed and recovered from the error Spontaneous action by a practitioner or staff member prevented event from reaching patient Action by the patient's family member prevented event from reaching patient Other reason Can t tell why near-miss did not reach patient Page 7 of 10

8 PATIENT INFORMATION Number of patient information reports submitted 2,502 1, PATIENT DEMOGRAPHICS Gender Male 1, Female 1, Can t tell gender Age range Neonate (0-28 days) Infant (>28 days < 1 year) Child (1-12 years) Adolescent (13-17 years) Adult (18-64 years) Mature adult (65-74 years) Older adult (75-84 years) Aged adult (85+ years) Can t tell age Hispanic or Latino ethnicity Hispanic or Latino Not Hispanic or Latino 2, Can't tell ethnicity Race American Indian or Alaska Native Asian Black or African American Native Hawaiian or Other Pacific Islander White 1, More than one race Can t tell race PATIENT HARM Degree of harm AHRQ Harm Scale Death Severe harm Moderate harm Mild harm No harm 1, Can t tell degree of harm Page 8 of 10

9 PATIENT INFORMATION (continued) Number of patient information reports submitted 2,502 1, PATIENT HARM (continued) Anticipated duration of harm Severe, moderate or mild harm Permanent: not expected to revert to approximately normal (i.e., patient s baseline) Temporary: expected to revert to approximately normal (i.e., patient s baseline) Can't tell anticipated duration of harm Time from discovery of incident to assessment of harm Within 24 hours 1, After 24 hours but before 3 days 1, Three days or later Can t tell time of assessment Impact on length of stay Length of stay extended Length of stay not extended 2, Can t tell impact on length of stay RESCUE Intervention(s) made after discovery to minimize harm One or more interventions made 1, Transfer Monitoring 1, Medication, including antidote Surgical intervention Respiratory support (e.g., ventilation, tracheotomy) Blood transfusion Counseling or psychotherapy Other intervention No interventions made Can t tell about intervention to minimize harm Page 9 of 10

10 PATIENT INFORMATION (continued) Number of patient information reports submitted 2,502 1, NOTIFICATION Notification to patient, family or guardian of incident Notification made 1, Notification not made 1, Can t tell whether notification made REPORTING, REPORTER AND REPORT INFORMATION REPORTER INFORMATION Role of person who reported the event or unsafe condition Healthcare professional 3,357 1, Doctor or dentist (including student) Nurse, NP, or PA (including student or trainee) 2, Pharmacist or pharmacy technician (including student) Allied health professional Healthcare worker Emergency service personnel Patient/resident, relative, volunteer, caregiver, or home assistant Other Can't tell role of reporter Page 10 of 10