RISK MANAGEMENT AND PATIENT SAFETY

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1 RISK MANAGEMENT AND PATIENT SAFETY Risk Management uses processes, methods, and tools to assess what can occur within the healthcare setting and to guide proactive decisions for implementing strategies to reduce or eliminate those risks. Key Areas of Focus: Protection of Assets This includes: Insurance Coverage Professional Liability Adverse Events Product Safety Communication Medical Records Occurrence Reports Fall Hot Line Grievances Call x44573 during business hours Available 24/7 via Operator Adverse Events Risk Management is response for reporting adverse events to the Connecticut Department of Public Health. Possible reportable adverse events include: perforations, falls with serious injury or death, hospital acquired pressure ulcers (Stage III and IV), specific surgical, environmental, or criminal events. All potential reportable adverse events need to be reported to Risk Management immediately by phone. Please refer to the Hospital s policy, Adverse Event Reporting, RM for additional information on reportable events. Complaints/Grievance All patient complaints are handled by the Patient Ombudsman X Grievances are written or verbal complaints regarding the patient s care made after the patient is discharged. Grievances are managed by Risk Management. Product Safety CALL RISK MANAGEMENT IF THERE IS A PRODUCT FAILURE OR A PRODUCT RELATED INJURY Identify product type, manufacturer, model number and serial number. Save disposables and packaging. Label equipment as broken/do not use and remove from service. DO NOT DISCARD. DO NOT USE ON ANOTHER PATIENT.

2 Medical Records Business Record/Legal Document. The medical record is the property of the Hospital. The patient owns the information in the medical record. The information contained in the medical record is protected by the Health Insurance Portability and Accountability Act (HIPAA). If you are unsure whether protected health information (patient information) can be disclosed, contact the Hospital s Privacy Officer. The Hospital can incur penalties if protected health information is disclosed without proper authorization. Other privacy considerations o Do not discuss protected health information in public areas o Safeguard all protected health information on computers used for charting protected health information, whether in the hallway or at the nurses station or elsewhere. o Documentation must be: Accurate, objective, factual. No accusations or finger pointing. Completing the Medical Record o Date, Time and Sign each entry. o Use black ink. o No blank spaces. o Must be legible. o Remember to READ the record. o Prohibited abbreviations are available on the Infonet. o Information must be accurate, objective, factual. o No accusations or finger-pointing. Occurrence (incident) Reports Occurrence reports are used to report unanticipated occurrences. Unanticipated occurrence any unusual event or circumstance that is not consistent with the routine operation of the Hospital and/or the staff. It may be an error, a poor outcome, or an accident which could have or has resulted in a patient/visitor injury. Purpose - to identify occurrences. o To monitor quality and safety. o Improve processes. Occurrence reports are NOT a substitute for documentation in the medical record. Incident report is NOT part of the medical record. It is a confidential business document.

3 OCCURRENCE REPORTING Incident Reports are completed to provide notification of incidents or events that have occurred involving patients, visitors, staff, equipment, or facilities that may affect the quality of patient safety, patient care, or that may become a potential liability for the institution. An Incident Report should be completed when an event is inconsistent with the standard of care, has caused an injury or has the potential to cause injury: i.e. a near miss. It is always better to over report than under report. Risk Management reviews all Incident Reports and will investigate those which may require immediate action to ensure that the appropriate follow-up is in place. Incident Reports are also reviewed periodically to identify and document trends within our care system. Do s Have the staff member most familiar with the incident complete the report. Complete the report in its entirety and print legibly. Provide a brief narrative of the incident which is objective and is a description of only the facts. Use quotes when applicable regarding statements made by patient, visitor, etc. Have the patient examined by a physician or licensed practitioner and have that practitioner document their findings on the incident report. Document in the patient s medical record an objective description of the incident including follow-up interventions or observations. Remove any suspect failed equipment from service and contact Clinical Engineering immediately. Present completed report directly to supervisor for investigation and recommended corrective action. Call Risk Management immediately if an incident is of a serious nature. Don ts Provide opinions or conjecture regarding the incident on the incident report. Ask a patient or their family member to complete the report. Make copies of the incident report. Advise patients, visitors, or family members to contact Risk Management for a copy of the report Incident Reports are for internal hospital use only. Limit the narrative because of size constraints on the document there is room on the reverse side of the form. Limit events submitted on the incident report to the category types listed on the document. If there is no corresponding incident type submit the incident as Other. File the incident report in a patient s medical record and do not document in the medical record that an incident report was submitted. Discard original packaging or medical device when a product failure is suspected please refer to the hospital s Medical Device Reporting Policy for additional instructions.

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5 FALL HOT LINE AFTER THE FALL, DON T FORGET TO CALL! Call the Risk Management Fall Line at to report all falls. The information should include the following: - Patient s name - Medical record number and DOB - Description of injury - Name and unit of reporter Please be sure to complete the Incident Report and forward to Risk Management as quickly as possible. Thank you FALL LINE Ext

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7 Personal Property Conduct a thorough inventory and document belongings during admission and each transfer on the Personal Property Record sheet in the medical record. Encourage patients have a family member take their personal belongings, including valuables home. Encourage patients to have valuables not sent home locked in the Hospital safe. The Hospital will NOT reimburse a patient for any lost belongings that remain with the patient. NEVER promise reimbursement from the Hospital. NEVER express an opinion to the patient or family regarding Hospital liability. If theft of personal property is suspected, call Security.