Event Reporting System Reporter’s Guide

Background

UCLA Health System is committed to providing the highest qualityhealth 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 web-based 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 ManagementPolicy 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 PolicyHS 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 theauthority of the Quality Management Department.

• The investigations and/or resolutions of events are confidentialpeer review protected activities. All paper and electronic reports, discussions, and other documents pertaining to evaluation and/orreporting 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 thefollowing major categories:

Medical treatment problem/complicationSurgical treatment problem/complicationPerinatal problemEquipment / device problemMedication ErrorFallsDiagnostic / testing problemAdmission/discharge/ transfer problem, leaving against medical advice

Fire/environmental hazardBehavior ProblemIV transfusion problem (including blood and blood products)Suicide attemptsViolence 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

What is the role of my manager and the administrator?

Administrator Role

Serves two roles in the system.

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.

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: [email protected]

How To Get 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 ReportSystem Access

How To Submit A ReportSigning 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 ReportEdit 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

Submit A Report

Click on New Event

Your Name

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 ReportAdd 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 ReportAdd 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

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



General Questions

Select the Location and the Unit where the event occurred




General Questions

Select your Home Department using the drop-down menu

If applicable, indicate if the event is related a National Patient Safety Goal



General Questions

Complete these questions and applicable fields on every report to determine if harm occurred and the results of any intervention



Category Selection

Click on the icon to select the Category that best matches the type of event being reported



Subcategory Selection

Select the Subcategory that best matches the type of event being reported



Subcategory Questions

Complete applicable questions to provide additional details about the event for the subcategory previously selected

Not all subcategories will have related questions


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




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


Event SummaryThis 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 forwardTo submit the event report, click Submit Event button from this page, Step 6- Event Summary


How To Submit A ReportAdd New Event: Final Steps

Click OK to submit the event when asked if you would like to submit the report.

An Event Confirmationappears 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 thetype 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 [email protected]

Thank You!

This presentation was created by BRITE Training in partnership with the UCLA Hospital System and FPG Ambulatory Operations.

October 2008

Event Reporting System Reporter’s Guide

Documents

Transcript of Event Reporting System Reporter’s Guide