Event Reporting System Reporter s Guide

Event Reporting System Reporter s Guide

Background UCLA Health System is committed to providing the highest quality health care to all patients. An important part of the work we do to deliver quality care is ensuring that we maximize patient safety. We achieve patient safety in many ways most importantly through an organizational culture that quickly finds out errors and takes action to address them. An adverse event is an error, violation or deviation from standard procedure that puts patients, employees or the public at risk for harm, loss, injury or death. A significant violation of procedure that disrupts the health system s ability to function properly is also an adverse event.

Background Continued Federal and state laws as well as UCLA Health System policies require us to report, track and take corrective action in response to adverse events. University of California developed a web-based reporting system the Event Reporting System (EVR) that has been used by hospital providers and staff since 2003. The Event Reporting System (EVR) will be rolled out in the fall of 2008 for use by all ambulatory clinics as well. Only licensed clinics are required by the California Department of Public Health to report the Never 27 Adverse Events. However, we are offering this webbased tool to track and communicate events in all clinics. Working in this way together, we will enhance our ability to improve processes and performance for better patient care.

Introduction This guide will present information on the UCLA Event Management Policy and your role as a FPG Event Reporter. You will learn: The definition of an event and event types Your role in reporting event incidents The role of your manager and the administrator How to get access and submit an event report Helpful tips when using the system

Event Management Policy HS 0328 It is the policy of the UCLA Health System to thoroughly review events in order to understand the causes that underlie these occurrences and to make changes in the organization s systems and processes to reduce the probability of such an event in the future. The Event Reporting System (EVR) shall be used to report any occurrence that is not consistent with routine operations that may potentially or actually result in injury, harm, or loss to any patient or visitor at UCLA Health System and outpatient clinics.

Confidentiality of Reports Event reports of incidents and/or occurrences are confidential communications protected by the attorney-client privilege. They are not to be released to patients or other persons, even in response to a subpoena. All such reports shall be kept under the authority of the Quality Management Department. The investigations and/or resolutions of events are confidential peer review protected activities. All paper and electronic reports, discussions, and other documents pertaining to evaluation and/or reporting shall be deemed confidential and not subject to disclosure. No copies of paper or electronic forms, investigation reports, or other documents are to be made for any reason.

What is an event? An event is any occurrence that is not consistent with the routine operation of UCLA Health System or that potentially may, or actually did, result in injury, harm, or loss to any patient, employee, or visitor at UCLA Health System facilities including outpatient clinics. An event may also include a major violation of established procedure or a disturbance or unfavorable situation that could disrupt hospital functions.

What are the event types? Reportable events/occurrences include but are not limited to the following major categories: Medical treatment problem/complication Surgical treatment problem/complication Perinatal problem Equipment / device problem Medication Error Falls Diagnostic / testing problem Admission/discharge/ transfer problem, leaving against medical advice Fire/environmental hazard Behavior Problem IV transfusion problem (including blood and blood products) Suicide attempts Violence against on-duty personnel resulting in injury or involving the use of a firearm or other dangerous weapon

What is my role? An Event Reporter enters the event incident into the system by: Signing onto the web-based FPG Event Reporting System Answering the initial questions Writing details of the event Saving the report which is then stored in the database for management review

What is the role of my manager and the administrator? Manager Role Reviews events and performs most of the follow-up, from further investigation to examining trends, and potentially referring to another staff member. Can be involved in an event based on several different criteria: Category Subcategory Department Division Location Unit Severity

Administrator Role Serves two roles in the system. What is the role of my manager and the administrator? 1) Reviews events of particular importance and maintains and operates the overall system. 2) With a system-wide scope, utilizes much of the system s reporting capabilities to analyze and report trends.

How To Get Access Web-Based Access Open Internet browser and go to: www.eventreporting.mednet.ucla.edu -or- Click on Event Reporting System (EVR) from MedNet home page Assistance Email: eventreporting@mednet.ucla.edu

How To Submit A Report System Access Access the system from the noted URL or MedNet home page Click on the Faculty Practice Group link from the UCLA Event Reporting System Homepage

How To Submit A Report Signing On Enter your User ID and Password Your User ID and Password is the same that is used for PCIMS, Mainframe, or Payroll Click on LOGIN

How To Submit A Report Edit Profile or Add New Event Edit/Add Profile If you are a new user, you will be directed to the Edit Profile option to create your profile Your Name Submit A Report Click on New Event

Edit Profile Your Profile Complete the profile entry fields if you are a new user -or- Verify your profile for any changes and update if needed Click Save Profile to save and continue

How To Submit A Report Add New Event Welcome Page Contains brief instructions and provides any updates to the Event Reporting System Click Enter New Event to continue

How To Submit A Report Add New Event: Step 1 General Questions Select whether the event involved a patient, visitor, employee, or none If a patient, enter the Patient s Medical Record Number under MRN (a.k.a. patient ID) Click Next to continue

How To Submit A Report Add New Event: Step 1 General Questions If a patient MRN was entered on the previous page, verify the Patient s Name, Gender, and DOB -or- Enter the Employee or Visitor Name (non-patient event) Enter Event Date and Time Click Next to continue

How To Submit A Report Add New Event: Step 1 General Questions Select the Location and the Unit where the event occurred Click Next to continue

How To Submit A Report Add New Event: Step 1 General Questions Select your Home Department using the drop-down menu If applicable, indicate if the event is related a National Patient Safety Goal Click Next to continue

How To Submit A Report Add New Event: Step 1 General Questions Complete these questions and applicable fields on every report to determine if harm occurred and the results of any intervention Click Next to continue

How To Submit A Report Add New Event: Step 2 Category Selection Click on the icon to select the Category that best matches the type of event being reported Click Next to continue

How To Submit A Report Add New Event: Step 2 Subcategory Selection Select the Subcategory that best matches the type of event being reported Click Next to continue

How To Submit A Report Add New Event: Step 3 Subcategory Questions Complete applicable questions to provide additional details about the event for the subcategory previously selected Not all subcategories will have related questions Click Next to continue

How To Submit A Report Add New Event: Step 4 Event Detail Explain and describe details of the event in a clear and concise manner that is pertinent If known, describe the impact the event had on the patient/staff/visitor Click Next to continue

How To Submit A Report Add New Event: Step 5 Witnesses Click Add button to include a witness to the event or to enter any known information about a witness Click Add button again to save the data entered Click Next to continue

How To Submit A Report Add New Event: Step 6 Event Summary This page allows you to review the event information entered for accuracy. To make corrections, use the Step Map (menu bar at top of page) to navigate directly to the step that needs updating or click Back button (bottom of page) until you reach the page you wish to update Click Next button to save updates and continue forward To submit the event report, click Submit Event button from this page, Step 6- Event Summary

How To Submit A Report Add New Event: Final Steps Click OK to submit the event when asked if you would like to submit the report. An Event Confirmation appears to indicate the report was completed and submitted successfully

What happens after I submit a report? After an event report is submitted, an email notification is sent from the Event Reporting System to the manager of the category of the type of event indicated and of the location indicated on the event report. The event report will also be reviewed by the Quality Management Department. Follow-up action(s) will be taken as appropriate to the type and severity of the event reported.

Helpful Tips Questions in boldface or have an asterisk ( ) must be answered before the system will let you proceed Navigate to the previously answered sections by using the Back button at the bottom of each page or the Step Name link at the top of the Event Report Events cannot be saved mid-way through entry be prepared to complete the event from start to finish

Helpful Tips A link to Frequently Asked Questions is provided on the UCLA Event Reporting System homepage For help or questions, contact the Event Reporting System by email at eventreporting@mednet.ucla.edu

Thank You! This presentation was created by BRITE Training in partnership with the UCLA Hospital System and FPG Ambulatory Operations. October 2008