Part Two

- Policies for unexpected events

A list of facts that can be reported

Incident reporting policy

Policy:

A policy that explains the system for reporting near misses/incidents that enable employees to report them in order to help in continuous improvement of performance.

Purpose:

To provide an organized mechanism in the hospital to identify problems that lead to negative outcomes for patients, visitors, or employees in order to detect them early and prevent them from occurring.

Definitions:

· Near miss: An unplanned event with the potential to cause harm that was intercepted in time or by chance resulting in no harm to the person.

· Incident/accident: Any incident that occurs in the hospital (that does not represent routine patient care) that negatively affects or has the potential to affect the health or lives of patients, visitors, or hospital workers.

procedures

General procedures:

· The report must be written and completed by the person who discovered the accident or the person involved in this accident.

· The report must be written immediately after discovering the incident and submitted to the Quality Coordinator no later than 48 hours.

· The quality coordinator presents the report to the head of the relevant department and the hospital director to take corrective measures.

· Confidentiality must be observed in dealing with or maintaining these reports, while limiting access to them to persons with authority to do so.

· Do not use the information in this report as a means of taking disciplinary action against anyone.

· These reports should generally be discussed at Quality Committee and Medical Board meetings for educational purposes or to establish regulations limiting their occurrence.

· Items that make up the report

· Information about the infected person and the department he is in.

· The type of incident/unexpected event that has significance.

· Information about the near miss/accident/unexpected event that has significance.

· Description of the incident, indicating any action taken immediately after the discovery and the factors that led to this incident.

· Corrective actions taken.

· Data of the person who discovered the incident/unexpected event that has significance. Filling out this part is not mandatory.

· The department head verified the report.

· Instructions from the hospital director.

People responsible for writing the report

· All hospital employees, including doctors, nurses, pharmacists, chemists, radiology technicians, and non-medical service personnel.

· Corrective action plan and assigned responsibilities in the event of unforeseen accidents:

· After the report reaches the hospital’s quality coordinator (within 48 hours of the incident), he reviews it and returns to the head of the department in which the incident occurred and the person or persons who discovered the incident to find out the reasons that led to the incident. This is done within 48 hours of the report reaching the quality coordinator.

· The quality coordinator (or his designee from the quality team) classifies this incident as (specific to environmental safety - specific to medications - specific to patient safety and security)

· The Quality Coordinator (or his designee from the Quality Team) refers to (the Environmental Safety Officer - the Pharmacy Manager - the Patient Safety and Security Officer) according to the classification of the incident to make recommendations with the Quality Coordinator (or his designee from the Quality Team) to prevent this incident from recurring again. Other.

· After setting the necessary recommendations to avoid the occurrence of this incident, a corrective plan will be developed to implement these recommendations by the quality coordinator, the responsible person according to the classification of the incident, and the head of the department in which the incident occurred.

· The corrective plan includes recommendations, who is responsible for implementing each recommendation, the time frame for implementation, and the resources required.

· The quality coordinator (or his designated member of the quality team) follows up on the implementation of the established corrective plan and submits a report on it for discussion at the quality committee meeting.

Responsibilities

· The employee who discovered the accident

· Rapid intervention to protect or support the patient’s health condition.

· Immediately inform the existing doctor

· Writing the report before the end of the shift.

· The doctor who was informed of the accident

· Recording the result of the medical examination and the required medical care.

Hospital manager

· Review the condition and ensure that corrective actions have been implemented and provide any assistance required.

Quality coordinator

· Monitor all reports and ensure that all important steps to resolve the issue have been completed.

· Writing a monthly summary of all reports.

· Writing a quarterly report to the Quality Committee for discussion.

· Maintain a file of all reports for three years.

Occupational safety and health officer

· Examine all occupational safety and health reports to review safety-related incidents.

· Form a team from the Occupational Safety and Health Committee to review safety-related incidents.

· Recording the inspection results and corrective actions taken in the report.

· Return the completed report to the Quality Coordinator.

· Writing a monthly summary and presenting it to the Occupational Safety and Health Committee.

Responsible for implementation:

· The employee who discovered the accident

· The physician who has been notified

· Head of Department

· hospital manager

· Quality Coordinator

· Occupational safety and health officer

The Reviewer

· Egyptian accreditation standards.

· Regulating laws and regulations

Models

· Incident report form

Attachments

· Accidents and near misses that must be reported to the hospital.

Preparation	Review	The trust

Policy name

Submit an incident report

Policy number

[Issue date and number

Review Date

Number of pages

Artificial kidney unit

Patient escapes

The patient's suicide, suicide attempt, and violence.

Unexpected mortality and complications including those resulting from institution-acquired infections.

Confirmed blood transfusion reactions (except for routine adverse reactions such as chills and fever).

Significant events in anesthesia and analgesia that caused harm to the patient.

Significant differences between preoperative diagnosis and postoperative diagnosis including surgical pathology findings.

Significant adverse drug reactions that cause patient harm.

Significant medication errors that caused harm to the patient, such as:

Giving the wrong medication.

Giving the wrong dose.

Giving medication incorrectly.

Giving medication to a wrong patient.

Related to operations:

Cancel the operation

Unexpected removal of any organ

Wrong patient

Incorrect counting of tools

Cases of error in the operation (patient - operating party - procedure)

Leaving a foreign body in the patient.

· Related to the laboratory:

Incorrect sample data

His eye is wrong

Improper storage

Incorrect laboratory results

Related to the hospital:

Visitor injured

Bed sores

Incorrect needle injury

· Security neutrality:

Theft or loss of personal property

Fight with a visitor or patient

Failure to follow hospital policies

attempt to suicide

· Fire and safety:

a fire

Chemical spill

One of the emergency exits is blocked

Expired fire extinguisher

Gas leak

Water leak

Unsafe electrical wires

Serious physical or psychological harm to a patient, employee, or visitor (nerve damage - loss of a limb or organ - death)

Preparation	Review	The trust

Significant Error/Accident/Unexpected Event Report Form

1. Casualty data:
The name: ...................................... File/card Number:..................Age: ........... Type: ..................
Section: ...............................................Patient admission date: ................................
□ Patient □ Employee □ Visitor □ Other(specify)...................
2. Incident type:
□ Error □ Accident □ Significant unexpected event
( Locate ) ............................................... .................................................. ......
3. Information about the incident:
The date: ....../...... / 20 Hour: .......... (am/pm)
Location in detail: ............................................... ..............................................
1. Describe the incident and write down the factors that led to it:

1. Corrective actions taken:

1. Amount data:
The name: ................................................ ...... The department he works in: .............................
Name of the doctor who was notified: ............................................ Report writing start time: ................
Name of witness (if any): ........................................ ...... His phone number: ............................
1. Admin data:
The name: ......................................... Function:.........................
the date: ...... /....../ 20 Hour: .......... (AM/PM) Signature: ..........................
1. Medical supervision data in the event of an injury: (including examining the patient - the required tests and their results - diagnosis)




The name: ...................................... The date: ....../...... / 20 Signature: ...................
Medical follow-up data:



The name: ......................................The date: ....../....../ 20 Signature: .........................
1. Department Head Instructions: (With verification of the accuracy of what is stated in the report)



The report is submitted to Mr. Doctor/Hospital Director for presentation and necessary action.
The name: ...................................... The date: ....../....../ 20 Signature: ........................
1. Hospital director instructions:



The report is submitted to the Quality Improvement Committee coordinator for recommendation, implementation and preservation.
Signature of the hospital director: .............................................. .... Done in : ...... /....../ 20

Intensive analysis policy when unexpected events occur

Policy: The existence of standards and processes for intensive analysis of significant and undesirable unexpected events.

Purpose: To increase public knowledge about events, their causes, and strategies to prevent them, and focus the hospital's attention on understanding the reasons behind this event and changing hospital systems and processes in order to reduce the possibility of such an event occurring in the future.

Definitions:

· A significant unanticipated event is any unexpected event in health care that results in death or serious physical or psychological injury to a patient.

Procedures:

· A report on the occurrence of the event is written as per policy.

· The quality coordinator selects a team consisting of people close to this event and a member of the hospital’s quality team to analyze the reasons and determine the basic factors behind the occurrence of this event, provided that this is done within a month of forming the team.

· The analysis identifies changes that could be made in systems and processes (either through redesign or development of new systems or processes) that would reduce the risk of such events in the future.

· The analysis must be accurate, documented, and comprehensive, including the following:

· Identify the human factors and other things that are directly related to the event and the processes and systems relevant to its occurrence.

· Analyze basic systems and processes through a series of questions.

· Identify risks and their potential contributions to this type of event.

· Identify potential improvement in processes or systems that would lead to a reduction in the likelihood of such events occurring in the future.

· After identifying the root causes, the team will develop a corrective plan to avoid these causes in the future, provided that the time frame for implementing this plan does not exceed three months.

· time frame :

· The root causes must be analyzed and a corrective plan must be developed within a month of the event occurring.

· The corrective plan must be implemented within a period not exceeding three months.

· The root cause analysis and corrective plan implementation are reviewed by the hospital’s Quality Committee.

Responsible for implementation:

· Quality Committee

· work team

· People responsible for implementing the plan

The Reviewer:

· Egyptian accreditation standards.

· Regulating laws and regulations.

Models:

· Incident report form

Preparation	Review	The trust