RISKMASTER Entering an Initial Incident / Event Report

Transcription

1 RISKMASTER Entering an Initial Incident / Event Report (A guide for the staff member)

2 RISKMASTER Page 2 UPMC physicians and staff members are required to report serious patient incidents and events. INCIDENT An event, occurrence, or situation involving the clinical care of a patient in a medical facility which could have injured the patient but did not either cause an unanticipated injury or require the delivery of additional health care services to the patient. Use online reporting. SERIOUS EVENT An event, occurrence, or situation involving the clinical care of a patient in a medical facility which results in death or compromises patient safety and results in an unanticipated injury requiring the delivery of additional health ENTERING RISKMASTER Riskmaster is entered from the patient chart on erecord if the reporter has access, through the desktop icon (where available), or throught the UPMC Infonet by clicking on A to Z listing, then scrolling to the I section and clicking on Incident reporting (nonn-employee). If Riskmaster is entered from the chart of the patient on whom an incident is being reported, the form will prefill with all of the patient information. Otherwise, you will have to enter all patient information. A link is available on the toolbars. If Riskmaster must be entered using the desktop icon or the Infonet link, NO DATA will preload, and all information described below as prefilled will have to be added by the reporter. The Login Screen will open.

3 RISKMASTER Page 3 Select UPMC St. Margaret or St. Margaret Outpatient Center (Harmar employees only) from the dropdown menu beside Facility: and click login. The following screen will appear: Click on Initial Incident Event Reporting. The following screen will open:

4 RISKMASTER Page 4 The form will then open, already preloaded with the patient s information. Each section of the form is broken down below. The patient data form should be prefilled. Verify the information is correct.

5 RISKMASTER Page 5 The Event Information form will need filled in. The date and time of event should be accurate to the time the actual event occurred. The date can be either be entered manually in a mm/dd/yyyy format or be selected by using the calendar, accessed by clicking on the ellipse button ( ) directly to the right of the date box. The date and time reported should reflect the ACTUAL TIME the Riskmaster report is being filled out. All times are recorded in military time (24-hour). Use the pull down menu to choose the classification of person to whom the event occurred. In most cases, this will be an In-patient. The service code should be prefilled. Choose the event type. Use Other? only for incidents such as IV infiltrates, pressure ulcers POA, acquired pressure ulcers, patient leaving AMA, and patient injuries other than a fall. The supervisor should be made aware of any Riskmaster entry, so this box should always get checked. Supervisor is defined in the systemwide policy as the immediate supervisor. This is either the Charge Nurse or Unit Director. If the event involves defective equipment, make sure the equipment is red tagged and the tag number is recorded on the Riskmaster form. The event description box is a free form text entry. Provide factual details about the incident. Do not place any names in this description. Use only initials or titles (RN, MD, PCT, patient, visitor, etc.) when describing people in the description. This box should include ALL pertinent information regarding the incident. The Actions taken field denotes any actions taken by staff at the time of the incident. Each item must be chosen individually (multiple selections cannot be made at one time), so the action must be repeated for each action that was taken. Choose ALL appropriate actions. Access the pop-up box by clicking the ellipse button ( ) directly to the right of the Actions Taken box. To remove an item from the list, highlight it and click on the minus button.

6 RISKMASTER Page 6 This is what the Actions taken pop up box will look like: Physician information will prefill. Click on the lookup button to confirm the doctor (this must be done before the form can be submitted.

7 RISKMASTER Page 7 The Witnessed / Reported by section is where names of all witnesses to the incident. This includes Doctors, Nurses, PCTs, Aides, visitors, and ancillary staff. Include as much information available about the witness as possible. Each person needs to be added individually. Include the names of all witnesses. To add a name, select the type of witness from the dropdown menu and then fill in that individual s contact information. When finished, click the Add button to the right. If more than one person has witnessed the event, repeat the process by entering each individual s contact information and clicking Add again. The Submitted by section is the person filling out the Riskmaster. This is the person filling out the form. Per the IIER policy, this includes Staff members, physicians, employees, volunteers, students or other persons who gain knowledge of a Reportable Patient Event, Reportable Staff Event or Other Reportable Event (p. 2). Provide the Last Name and First Name as the reporter of the incident/event and select the best choice of job descriptions from the drop-down menu. Submitting the form When the form is completed, click on the Submit button to enter the report. For Riskmaster reports involving falls, medication events, or Adverse Drug Reactions, a follow-up page will open. These must be filled out as completely as possible. Once the follow-up screens are completed and submitted (if necessary), the screen will return to the Initial Incident Event Reporting Screen. Select Log out to exit Riskmaster.

8 RISKMASTER Page 8 Falls Follow-up Screen The demographics section of this form prefills from the initial Riskmaster form, including the event description. Answer all of the questions listed in the second section as seen below. For boxes with pre-filled answers, use the ellipse button to the right of the box.

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10 RISKMASTER Page 10 Medication Event Follow-up Screen Fill out all of the Required Information Section of the form. While the additional information section is not required, adding information in this section will allow investigators to better understand the nature of the error. The event description will prefill from the initial Riskmaster form. Clicking on each item will open a pop-up box to enter the required information. Examples of the pop-up boxes are shown on the following pages.

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13 RISKMASTER Page 13 Adverse Drug Reaction Follow-up Screen Event Description prefills. All boxes are free-text. Complete form with as much information as is available.

14 RISKMASTER Page 14 References: UPMC (2008). Reporting serious events and incidents. Retrieved from UPMC infonet. Initial Incident/Event Reporting (2012). UPMC Policy and Procedure Manual. Retrieved from UPMC Infonet.