OCCURRENCE VARIANCE REPORTS

Presentation Outline

What is Occurrence / Variance Report (OVR)

Near Miss

Basic Categories to include on an OVR

OVR sequences

Role of Quality Department related to OVR’s

Definition:

An incident that occurs in hospital property which is out of the ordinary and/or deviates from standard practice or behavior and affects the health & safety of patient of patient/staff/visitors

Definition:

Near Miss:

An event or situation that could have resulted in an adverse event but did not (occur) either by chance or through timely intervention.

Example: Epinephrine was almost administered instead of Lidocaine but uncovered during the final check of the nurse.

Sentinel Events:

Is defined as unexpected occurrences that involve deaths or serious physical injury or psychological injury or the risk event.

Basic Categories to Include on an OVR:

Medication and Intravenous errors

Reactions to medications or blood requiring

intervention

Falls

Surgical or Diagnostic error

Newborn injuries (skull fracture, brachial palsy, paralysis, shoulder dystocia)

Burns, untoward outcomes or self inflicted injuries

Anesthesia injuries

Trauma

Suicide or attempted suicide

Assault – patient/staff/visitor

Patient elopement

DAMA patients

Visitor accidents

Employee Injuries

Lost or retained operative material

Malfunctioning equipment or improper utilization of equipment or improper utilization of equipment that results in or has potential of resulting in patient injury.

Wrong results affecting patient treatment

Delays in reporting highly critical results

Incorrect labeling of specimens

Loss or damage to property

Injuries to patient during treatment

Patient complaints

ALL INCIDENTS WHICH NEEDS TO BE REPORTED

MUST BE DOCUMENTED ON AN Occurrence/

Variance Report/ form

OVR must be:

Completed by the person finding the incident

Completed in full

The person reporting the OVR must inform the department supervisor on duty in their area immediately

Any OVR of a serious nature must be reported to the Duty Manager (out of hours) for the immediate action.

Forwarded to the Quality management/

Performance Improvement Manager within

24 hours (48 hours if the OVR requires

investigation by the initiating department)

If requires investigating/forwarding to a

department other than the initiating

department for follow up this will be carried

out by the PI Management

Any OVR given to your department for follow

up MUST be returned to the QM/PI Manager

within 48 hours.

No photocopies of OVR are allowed as they

are classed as confidential documents for

Risk Management processes.

Role of Quality Department

Receive the OVRs, must be within 24 hours from the occurrence.

Investigate the incident whatever to whom/or and with whom.

Correct the process if we need to correct, in cooperation with concerned department.

Therefore….

It advised that each department have their

own logbook of OVR and follow up reports

for future reference if required.

Sentinel Event vs. Near Miss

A hospital operates on the wrong side of the patient’s body.

A death or loss of function following a discharge against medical advice (DAMA)

Medication errors that do not result in death or major permanent loss of function.

Suicide other than in an around-the-clock care setting or following elopement from such a setting.

Sentinel Event vs. Near Miss

Minor degrees of hemolysis not caused by a major blood group incompatibility.

A foreign body, such as a sponge or forceps, that was left in a patient after surgery.

A patient commits suicide within 72 hours of being discharged from the hospital setting that provides staffed around-the-clock care.

Any intrapartum (related to the birth process) maternal death.

Sentinel Event vs. Near Miss

Any Sentinel event that has not affected a recipient of care (patient, individual, resident)

A patient is abducted from the hospital where he/she receives care, treatment, or services.

Hemolytic transfusion reaction involving major blood group incompatibility.

Unsuccessful suicide attempts unless resulting in major permanent loss of function.

GOOD LUCK ON YOUR NEXT. . .

O.V.R.