Part Two

- Unexpected events policy incident reporting policy

Policy name

Submit an incident report

Policy number

Issue date and number

Review Date

number of pages

All hospital departments

Politics :

A policy clarifying a reporting system for near misses / incidents that enables employees to report them in order to assist in continuous performance improvement.

Purpose :

Provide an organized mechanism in the hospital to identify problems that lead to negative outcomes for both patients, visitors or employees in order to detect them early and prevent their occurrence.

Definitions :

* Near fault: an unplanned accident with the potential to cause damage that was intercepted in time or by chance resulted in no harm to the person.

* Incident / accident: any incident that occurs in the hospital (not representing routine patient care) that negatively affects or could affect the health or life of patients, visitors or hospital staff.

Procedures

General procedures :

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

* The report must be written immediately after the discovery of 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, limiting access to them to persons with authority for this.

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

* These reports should generally be discussed at meetings of the quality Committee and the medical board committee for educational purposes or to develop instructions that limit their occurrence.

Constituent items of the report

* Information about the infected person and the department in which it is located.

* The type of unexpected incident / event that is significant.

* Information about the near error / incident / unexpected event that is significant.

* A description of the incident with an indication of any action taken immediately after the discovery and the factors that led to this incident.

* Corrective actions that have been taken.

* The data of the person who discovered the unexpected incident / event that has significance and filling this part is not mandatory.

* The head of the department checked the report.

* Instructions of the hospital director.

The persons responsible for writing the report

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

Plan corrective actions and assigned responsibilities in case of unforeseen accidental events :

· After the report reaches the quality coordinator at the hospital (within 48 hours of the incident), he reviews it and refers to the head of the department where the incident occurred and the person or persons who discovered the incident to find out the reasons that led to the incident, and this is done within 48 hours of the report's arrival to the quality coordinator.

* The quality coordinator (or whoever is assigned by the quality team) classifies this incident in terms of being (environmental safety - medication - patient safety)

* The quality coordinator ( or whoever is assigned by the quality team) will refer to the ( environmental safety officer – pharmacy manager – Patient Safety and security officer ) according to the classification of the incident to make recommendations with the quality coordinator (or whoever is assigned by the quality team) not to repeat this incident again.

* After making the necessary recommendations to avoid the occurrence of this incident, a corrective plan is developed to implement these recommendations by the quality coordinator and the responsible person according to the classification of the incident and the head of the department where the incident occurred.

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

* The quality coordinator (or whoever is assigned by the quality team ) follows up the implementation of the set corrective plan and submits a report on it for discussion at the meeting of the quality Committee.

Responsibilities

The employee discovered the incident:

* Rapid intervention to protect or support the patient's health condition.

* Immediate notification to the existing doctor

* Write the report before the end of the lip.

The doctor who was informed of the incident

* Registration of the result of medical examination and required medical care.

Hospital director

* Review the case and ensure that corrective actions have been implemented and provide any required assistance.

Quality coordinator

* Monitor all reports and ensure that all important steps to solve the problem have been taken.

* Write a monthly summary of all reports.

* Writing a quarterly report for the quality committee to discuss.

* Keep a file of all reports that is kept for three years.

Occupational Safety and health officer

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

* Formation of a team from the Occupational Safety and health committee to review safety-related incidents.

* Record the results of the examination and the corrective actions taken in the report.

* Return the updated report to the quality coordinator.

* Writing a monthly summary and presenting it to the Occupational Safety and health committee.

Responsible for implementation:

* Employee incident Finder .

* The doctor who was informed .

* Head of Department .

* Director of the hospital .

* Quality coordinator.

* Responsible for Occupational Safety and health.

References

* Egyptian accreditation standards-regulations and laws

Models

* Incident report form

Annexes

* Near accidents and errors that need to be reported at the hospital.

Preparation

Review

The trusted

A list of facts that can be reported

* Escape of the patient

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

* Unexpected mortality and complications, including those resulting from infections acquired from the institution.

* Confirmed transfusion reactions (routine adverse reactions such as chills and fever are excluded from this).

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

* Significant differences between preoperative diagnosis and postoperative diagnosis including the results of surgical pathology.

* Adverse reactions to significant drugs that caused harm to the patient.

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

◾ Giving the wrong medicine.

◾ Giving the wrong dose.

◾ Giving medicine the wrong way.

◾ Giving medicine to a patient is wrong.

Related to operations :

◾ Cancel the operation .

◾ Unexpected removal of any organ .

◾ Wrong patient .

◾ Wrong counting of tools .

◾ Cases of error in the operation (patient – operating entity – procedure) .

◾ Leaving a foreign body in the patient.

Related to the lab :

◾ Wrong sample data .

◾ Sample it wrong .

◾ Inappropriate storage .

◾ False lab results .

Related to the hospital :

◾ Injury of a visitor .

◾ Bed sores .

◾ Wrong needle injury .

Security neutrality :

◾ theft or loss of personal property .

◾ Fight with a visitor or a patient .

◾ Failure to follow hospital policies .

◾ Suicide attempt .

Fire and safety :

◾ Fire .

◾ A chemical spill .

◾ Blockage of one of the emergency exits .

◾ Expired fire extinguisher .

◾ Gas leak .

◾ Water leakage .

◾ Unsafe electrical wiring .

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

Preparation	Review	The trust

Significant Error/Accident/Unexpected Event Report Form

	1. Casualty data:
	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:
	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 in the 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 the formation of 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 the implementation of the corrective plan are reviewed by the hospital’s Quality Committee.

Responsible for implementation:

Quality Committee

work team

Persons responsible for implementing the plan

The Reviewer

Egyptian accreditation standards

Regulating laws and regulations.

Models

Incident report form

Preparation	Review	The trust