OP 4070 Reporting of OVA

POLICY/PROCEDURE
REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

TITLE: VARIANCES AND ACCIDENTS May 2005 2.0
IDENTIFICATION LAST REVISION NEXT REVIEW
NUMBER: OP 4070 DATE: DATE:
April 2018 April 2021
Sheet No. TRACKING
HOSPITAL(S) ALL HMC HOSPITALS /ENTITIES 1 of 13 HISTORY: SHEET
NO. 12
1.0 POLICY STATEMENT/PURPOSE:
1.1 This policy is formulated for all Hamad Medical Corporation (HMC) staff for reporting
occurrences, variances and accidents (OVA) through HMC Electronic Incident Reporting
System (EIRS).
2.0 DEFINITIONS:
2.1 Incident - An event or circumstance, which results in an unintended or unnecessary

harm to a person, whether he or she is a patient, employee, contractor or visitor. An
incident may include an event that results in a complaint about treatment, care or
service, loss or damage to HMC property or personal property.
2.2 Near Miss - Any process variation that did not affect an outcome but for which a
recurrence carries a significant chance of a serious adverse outcome.
2.3 Occurrence - An event that results in a loss to a third party due to bodily injury, or
property damage or destruction.
2.4 Variance - A difference between what is expected and what actually occurs; an event
that departs from expectations; an act contrary to a usual rule.
2.5 Accident - An unplanned, unexpected, and undesirable event, which occurs suddenly
and results in damage, injury or harm.
2.5.1 Although human error is commonly the final event before the incident or
accident happens, a faulty process or system is almost always the root
cause that permits or compounds the harm and should be the focus of
improvement.
2.6 Negligence: is the act of omission in the treatment or care of a patient by any of the
healthcare professional, which deviates from the accepted standard of care.
2.7 Severity level 1, negligible: Events/error that can cause no negative consequences or
no erroneous output.
Quality Improvement and Patient Safety (QPS) Regulatory, Accreditation and Compliance Services (RACS)
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2.8 Severity level 2, minor harm/damage: Events/error results in minor harm/damage

where first aid treatment only is needed and no further intervention is required.
2.9 Severity level 3, moderate harm/damage: Events/error results in moderate

harm/damage that necessitates hospitalization and required treatment.
2.10 Severity level 4, serious harm/damage: Events/error results in serious harm/damage,

requiring hospitalizations for intensive treatment and invasive procedure that hinders
return to work.
2.11 Severity level 5 sentinel: Events/error or catastrophic that results in unexpected death
and or major permanent loss of functions.
2.12 Misused – The use of the system incorrectly. Improper or misusing by entering
deliberately whether incomplete incident reports, reporting of the same incidents,
multiple entry of incomplete incident reports, irrelevant or non-OVA reports and the like.
2.13 Abused – A mistreat or abuse. An abuse of authority being the File Manager. Treating
any EntryUsers badly or harshly for personal gain; Preventing and threatening the
EntryUsers when reporting an incident; Falsification of incident report; Closure or
deleting unviewed incident reports or closure or deleting incident reports that are not
reviewed.
2.14 Access Rights – Any individual who has a valid HMC User ID and a Password has the
ability to access the system while in the HMC premises or resident. The permission
that is granted to an EntryUser or to an application as defined in; (see
Procedure/Process: 3.5 Responsibilities of Standard User in the System.)
2.15 Risk Assessment – is a systematic and effective method of identifying risks and
determining the most cost-effective means to minimize or remove them. It is an essential
part of any risk management Programme, and it encompasses the processes of risk
analysis and risk evaluation.
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2.16 Risk Matrix – is a matrix that is used during risk assessment to define the level
of risk by considering the category of probability or likelihood against the category of
consequence severity. This is a simple mechanism to increase visibility of risks and
assist management decision making.
2.17 Risk Assessment Scoring Matrix - (See appendix B).
3.0 PROCEDURE/PROCESS:
3.1 Hamad Medical Corporation (HMC) shall support a fair, just and transparent method of
dealing with incidents of occurrences, variances and accidents (OVA) in all its facilities.
3.2 All incidents of occurrences, variances and accidents (OVA), including near misses, shall
be reported, recorded, investigated and monitored, to provide a valuable opportunity for
maximizing the lessons learned from the outcomes of the events and to minimize
recurrences of similar events in the future.
3.2.1 The completion of the OVA reports shall be confidential, and may be made
anonymously and the outcomes of the investigations shall focus on the
systems and processes that have contributed to the particular incident or
event.
3.3 An occurrence variance and accident (OVA) report should immediately be initiated and
completed within 24 hours by the employee who first identifies the incident or near miss,
regardless of whether or not he or she was personally involved in the incident. (see
Appendix A – OVA Reporting Process Map).
3.3.1 If the incident is discovered at a later time, the employee who witnessed or
has knowledge of the incident should complete the report within 24 hours.
3.3.2 Note: Completing an OVA report is not an admission of liability; it is merely

a record that a hazardous or potentially hazardous event has been
discovered and requires action to prevent a recurrence.
POLICY/PROCEDURE

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NO. 12
3.4 The OVA report should be completed as soon as it is practical, but no later than 24 hours
and the report should contain the facts of the incident and should clearly and factually
identify any harm that resulted to the patient, employee or visitor.
3.5 The employee involved, or who witnessed the incident, should complete the OVA report
and record the facts of the incident:
3.5.1 Complete the details by selecting the options applicable to the incident type of the
OVA being reported;
3.5.2 Select the Facility/Service, Unit/Department and Section as the location of the
employee where he/she discovered the incident;
3.5.3 Select the Other Service(s)/Dept.(s) Involved where the incident occur or the origin
of the incident other than the location of the employee where he /she discovered
and reporting the incident;
3.5.4 Avoid recording opinions, judgments, conclusions, or derogatory remarks;
3.5.5 Record what immediate action was taken following the event to make the situation
safe and to prevent an immediate recurrence;
3.5.6 Document the facts of the incident also in the Nursing Notes, and/or
Physician Progress Notes in the Patient’s Medical Record.
3.6 The completed OVA report should be notified to the Section/Unit Head before
submission to ensure that the reported information is complete and any action taken to
protect patients, staff or visitors is recorded.
3.7 Anonymous Reporting where the staff member can select an option to report the incident
without his/her personal identification. Anonymity can prompt the staff members to report
an incident without fear of sanction, scrutiny and without fear confronting the supervisor.
POLICY/PROCEDURE

Sheet No. TRACKING
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3.8 Responsibilities of Standard Users in the Electronic Incident Reporting System

(EIRS), RL6
3.8.1 An individual with Administrator rights is able to:
3.8.1.1 Create and submit files

3.8.1.2 View, modify and add follow up to all files for all locations
3.8.1.3 Resolve or close files on the Resolution/Outcome screen
3.8.1.4 View, modify and/or delete all incomplete files
3.8.1.5 View, modify and add to follow up to all confidential files
3.8.1.6 Create reports in advanced report designer using the Report
Center
3.8.1.7 Post to the shared reports folder in the Report Center
3.8.1.8 Create auto reports
3.8.1.9 Create tasks
3.8.1.10 Create alerts
3.8.1.11 Delete files from the system
3.8.1.12 Access the Administration Module and all associated
customization tools/files to customize and configure the system
3.8.1.13 Set up users in the application User Table of the Administration
Module
3.8.1.14 Retrieved original reports and its data history
3.8.2 An individual with File Manager A rights is able to:

3.8.2.2 View, modify and add follow up to all files for all to which rights
are granted
3.8.2.3 Resolve or close files on the Resolution/Outcome screen
3.8.2.4 View, modify and/or delete incomplete files to which rights are
granted
3.8.2.5 View modify and add follow up to confidential files which the
individual is the specific File Owner or to which file level access
has been granted
3.8.2.6 Advance Report Designer / Report Center with Create and view
reports that include data to which rights are granted
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3.8.2.7 Create auto reports, if File Manager A has access to the full
application and not just web for
3.8.2.8 Create tasks
3.8.2.9 Create alerts, if File Manager A has access to the full application
and not just web form
3.8.2.10 Notify the Risk Management Section immediately and submit the
case review summary should Serious and Sentinel Events
happened in his/her Facility/Hospital
3.8.3 An individual with File Manager B rights is able to:

3.8.3.2 View details of all submitted file to which rights are granted, until a
file is closed/resolved, at which time the file is no longer
accessible to File Manager B.
3.8.3.3 Add follow up to all files to which the rights are granted until file is
closed/resolved, at which time the file is no longer accessible to
File Manager B
3.8.3.4 View details and delete, or complete and submit all incomplete
files to which rights are granted
3.8.3.5 View details and add follow up to confidential files to which the
individual is the specified File Owner or to which file level access
has been granted, until file is closed/resolved, at which time the
file is no longer accessible to File Manager B
3.8.3.6 View reports for those locations to which rights is granted
3.8.4 The File Manager B of his/her assigned Unit/Section shall review,

classify and grade all OVA reports using the severity level and submit to
the File Manager B of his/her Department for peer review;
3.8.4.1 Follow up OVA reports with severity level 3 for action plan,
implement, monitor and evaluate the effectiveness of the action
and or its recommendation
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3.8.4.2 The File Manager B of his/her assigned Department shall review,

consolidate and collate OVA reports with the File Manager B of
his/her Section/Unit, review reports with severity level 3 and
ensure that corrective actions and or recommendation is properly
implemented, monitored and evaluated.
3.8.5 An individual with Entry User rights is able to:

3.8.5.2 Add follow up to own created files that was kept incomplete
3.8.5.3 View and delete, or incomplete and submit all incomplete files
he/she has created
3.9 The Risk Management Section of Quality & Patient Safety Department shall:
3.9.1 Provide assistance and support to all Departments to customize the

electronic incident reporting system as deemed necessary for the facility.
3.9.2 Provide continuous educational awareness and workshop to the entire

Department on the electronic incident reporting system.
3.9.3 Liaise with the Department involved in the accident or occurrence, in order
to initiate an investigation if necessary.
3.9.4 Provide advice and support to all Departments to assist them in

formulating and implementing an action plan on all OVA reports.
3.9.5 Track and monitor progress of actions, recommendations for resolutions,

implementation of remedial measures, and conclusions to prevent
recurrences, and to refer any issues for clarification to the appropriate
Department Heads for a response within ten (10) working days.
3.9.6 Review / delete Incident Reports that has been “Save as Incomplete”
three (3) days or seventy two (72) hours after the Entered Date
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Sheet No. TRACKING
NO. 12
3.9.7 Conduct risk level and assign severity level on all OVA reports using
consequence rating, likelihood rating, level of the risk , monitor and
evaluate trends that pose risks to patients, visitors and staff (see Appendix
B – Risk Assessment Matrix).
3.9.7.1 Severity level 1, 2 and 3 incidents should be managed locally (in

the Department), using appropriate investigation techniques,
including Root Cause Analysis, if warranted.
3.9.7.2 Actions taken to prevent recurrence and to promote patient safety

are expected as part of the local management.
3.9.7.3 The results of the Root Cause Analysis and the action plans
should be submitted to the Risk Management Section for
monitoring and evaluating liaised with the Quality Reviewers in
each facility.
3.9.7.4 Severity level 4 (serious harm/damage) and Severity level 5

(sentinel events) should have an automatic chart review by Risk
Management Section to confirm the risk level of the incident.
These may be referred to the Adverse Medical Outcomes
Committee (AMOC) for information and further investigation.
3.9.7.4.1 The management team and Health Information

Management Department should ensure that
Electronic Medical Records are available for Risk
Management Staff.
3.9.7.4.2 Charts for all severity level 4 & 5 incidents should

be reviewed immediately by the Hospital/Entity
Chief Executive Officer, Executive Officer /
Medical Director or his/her designate.
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Sheet No. TRACKING
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3.10 All incidents reported with actual severity level 1 & 2 negligible / minor harm damage
should be reported for trending, study and quality improvement purposes.
3.11 All incidents reported with actual severity level 3, 4 and 5 must be preceded by a
preliminary review report within 3 working days.
3.12 All incidents reported with actual severity level 3, moderate harm damage must be
preceded by local department investigations and or Peer Review. Review by File
Managers and submit the reports electronically to Risk Management Section within 10
working days.
3.13 All incidents reported with actual severity level 4 & 5 serious harm damage / events or
error results in death (sentinel event) must be preceded by Corporate Investigation
Committee, Adverse Medical Outcome Committee (AMOC), Managing Director and
Chief Medical Office (CMO). (refer to OP 4055)
3.13.1 Investigation Committee should be formed by the Hospital/Entity,

Medical Director or his/her designee and assign the responsibility to
explore the incident/event and to submit reports to the Chief Executive
Officer or his/her designate, and Risk Management Section of Quality &
Safety Department.
3.14 Only specifically authorized staff may speak with the media or external bodies about an
incident and then only under the direction of the Managing Director’s Office. Under no
circumstances are any other HMC employees or contracted staff allowed to discuss
any aspect of any incident with the media or with any external person or organization not
bound by the Hamad Medical Corporation duty of confidentiality.
3.15 OVA reports are confidential documents that should not be placed in the patient’s
electronic medical record, and the completion of an OVA report should not be referred to
in the Electronic Medical Record.
POLICY/PROCEDURE

Sheet No. TRACKING
NO. 12
3.16 Care and Management of the Patients, Visitors and Staff
3.16.1 In the event of an occurrence, variance or accident (OVA), the Employee

or Department Supervisor should notify the Physician as appropriate. The
Physician should examine the patient and findings of the examination
should be documented in the Electronic Medical Records and on the OVA
report in the system.
3.16.2 If a visitor becomes ill or is injured on HMC premises, he or she should be

assisted to the Emergency Department (ED), and an OVA report should
be initiated by the witness, outlining the facts of the incident.
3.16.3 In cases resulting in employee injury, the employee should be made safe
by transferring him/her to Staff Medical Center or the Emergency
Department (ED) as appropriate for their needs per HMC policy CL 7263.
3.16.3.1 The report should be completed electronically by the injured staff

member as soon as he or she is able to do so or by the immediate
supervisor if the employee is physically unable to complete a
report.
3.17 Handling of Equipment at Scene of Incident
3.17.1 If a piece of medical equipment or medical device is involved in the event,

the device name, manufacturer, model and serial number should be noted
on the electronic incident reporting system OVA report.
3.17.2 The equipment involved in the incident should be removed from service,
clearly tagged as ‘OUT OF SERVICE - DO NOT USE’, isolated in a room
not normally associated with the use of that equipment, and left in exactly
the same state as it was at the time of the incident. No changes of any
type should be made to the fittings or settings, and under no
circumstances should staff attempt to repair the faulty equipment.
3.17.3 The equipment should not be used until it is checked and released for
service by Biomedical Engineering Department.
POLICY/PROCEDURE

Sheet No. TRACKING
NO. 12
3.18 Data Reporting
3.18.1 The Risk Management Section of Quality & Patient Safety Department will
compile, collate, and trend the data over time from all OVA reports and
incidents received for each month, and submit the findings, conclusions,
and/or recommendations quarterly and annually.
3.18.2 The quarterly reports of the incidents from the Risk Management Section
should be made available to the Hospital/Entity Chief Executive Officer,
Executive Director for the Quality Improvement and Patient Safety (QPS)
Committee in the facility/entity and/or relevant departments for their own
internal monitoring of the incidents/events.
3.18.3 Quarterly and annual reports of the incidents should be submitted to the
Managing Director, Chief of Medical Academic and Research Affairs,
Deputy Chief – Medical Education, Medical Academic and Research
Affairs, Hospital/Entity Chief Executive Officer – Executive Director, Chief,
Tertiary Hospital Group, Chief General Hospital Group, Chief Continuing
Care Group, for the effectiveness of actions taken in response to OVA and
their impact on preventing and/or reducing their occurrences.
4.0 DOCUMENTATION:
4.1 Document the facts of the incident and the actions taken to stabilize and ensure
patient safety in the Nurses Progress Notes, and/or Physician Progress Notes in
the Patient’s Medical Record.
5.0 REFERENCES:
5.1 Occurrence. (2018) BusinessDictionary.com Retrieved April 03, 2018, from

http://www.businessdictionary.com/definition/occurrence.html
5.2 Variance. (2018). TheFreeDictionary. Retrieved April 03, 2018, from
http://www.thefreedictionary.com/variance
5.3 Accident. (2018). Answers.com. Retrieved April 03, 2018, from
http://www.businessdictionary.com/definition/occurrence.html
5.4 rL solutions software for safer healthcare http://www.rlsolutions.com
POLICY/PROCEDURE

Sheet No. TRACKING
NO. 12
6.0 TRACKING HISTORY OF CHANGES:
REVISION DATE: CHANGES:

November 2017 Sheet no. 2
Section 2.13 : WebAdmin or Admin changed to File Manager & WebUser
changed to EntryUser
Section 2.14 : WebUser changed to EntryUser
Section : 3.7.1 : SuperAdmin changed to 3.8.1 Administrator
Section 3.8.1.6 : Report Producer changed to Advance Report Designer using the
Report Center
Section 3.8.1.7 :Report Producer changed to Report Center
Section 3.8.1.14: Retrieved original report and its history data – new/added
Section 3.7.2 : Admin changed to 3.8.2 File Manager A
Section 3.7.2.6 : Admin requires access to Report Producer changed to Section
3.8.2.6 : Advance Report Designer + Report Center with create
Section 3.7.2.9: Admin changed to 3.8.2.9 File Manager
Section 3.7.3 WebAdmin changed to 3.8.3 File Manager B
Section 3.7.3.2 WebAdmin changed to 3.8.3.2 File Manager B
Section 3.7.4 WebAdmin changed to File Manager B
Section 3.7.4.2 WebAdmin changed to File Manager B
Section 3.7.6 Web User changed to 3.8.5 EntryUser
Section 3.8.7.4.1 Medical Records Department changed to 3.9.7.4.1 Health
Information Management
Section 3.11 File Manager changed to 3.12 File Manager
Section 3.12 Medical Academic and Research Affairs change to 3.13 Chief Medical
Officer
Section 3.15.1 Medical Record added 3.16.1 Electronic
SUBJECT MATTER EXPERT CONTRIBUTORS: None
POLICY/PROCEDURE

Sheet No. TRACKING
NO. 12
7.0 ATTACHMENTS:
7.1 Appendix A – OVA Reporting Process Map
7.2 Appendix B – Risk Assessment Matrix
APPENDIX A
OVA REPORTING PROCESS MAP
OP 4070 Reporting Of Occurrences, Variances And Accidents Regulatory, Accreditation and Compliance Services (RACS)

APPENDIX B
RISK ASSESSMENT SCORING MATRIX
Table 1 Consequence scores (C) (Severity) and examples of the score descriptors
Consequence score (severity levels) and examples of descriptors
1 2 3 4 5
Domains Negligible Minor Moderate Major Catastrophic
Impact on the safety Minimal injury Minor injury or Moderate injury Major injury leading Incident leading to
of patients, staff or requiring illness, requiring requiring to long-term death
public no/minimal minor intervention professional incapacity/disability
(physical/psychologi intervention or intervention Multiple permanent
cal harm) treatment. Requiring time off Requiring time off injuries or
work for >3 days Requiring time off work for >14 days irreversible health
No time off work work for 4-14 days effects
Increase in length Increase in length of
of hospital stay by Increase in length hospital stay by >15 An event which
1-3 days of hospital stay by days impacts on a large
4-15 days number of patients
Mismanagement of
RIDDOR/agency patient care with
reportable incident long-term effects
An event which
impacts on a small
number of patients
Quality/complaints/a Peripheral element Overall treatment Treatment or Non-compliance Totally

udit of treatment or or service service has with national unacceptable level
service suboptimal suboptimal significantly standards with or quality of
reduced significant risk to treatment/service
Informal Formal complaint effectiveness patients if
complaint/inquiry (stage 1) unresolved Gross failure of
Formal complaint patient safety if
Local resolution (stage 2) complaint Multiple complaints/ findings not acted
independent review on
Single failure to Local resolution
meet internal (with potential to go Low performance Inquest/ombudsman
standards to independent rating inquiry
review)
Minor implications Critical report Gross failure to
for patient safety if Repeated failure to meet national
unresolved meet internal standards
standards
Reduced
performance rating Major patient safety
if unresolved implications if
findings are not
acted on
OP 4070 Reporting Of Occurrences, Variances And Accidents Page 1 of 3 Regulatory, Accreditation & Compliance Services (RACS)

1 2 3 4 5
Human resources/ Short-term low Low staffing level Late delivery of key Uncertain delivery Non-delivery of key
organisational staffing level that that reduces the objective/ service of key objective/service
development/staffing/ temporarily service quality due to lack of staff objective/service due to lack of staff
competence reduces service due to lack of staff
quality (< 1 day) Unsafe staffing Ongoing unsafe
level or Unsafe staffing level staffing levels or
competence (>1 or competence (>5 competence
day) days)
Loss of several key
Low staff morale Loss of key staff staff
Poor staff Very low staff No staff attending

attendance for morale mandatory training
mandatory/key /key training on an
training No staff attending ongoing basis
mandatory/ key
training
Statutory duty/ No or minimal Breech of statutory Single breech in Enforcement action Multiple breeches in
inspections impact or breech of legislation statutory duty statutory duty
guidance/ statutory Multiple breeches in
duty Reduced Challenging statutory duty Prosecution
performance rating external
if unresolved recommendations/ Improvement Complete systems
improvement notice notices change required
Low performance Zero performance

rating rating
Critical report Severely critical

report
Adverse publicity/ Rumours Local media Local media National media National media
reputation coverage – coverage – coverage with <3 coverage with >3
Potential for public short-term long-term reduction days service well days service well
concern reduction in public in public confidence below reasonable below reasonable
confidence public expectation public expectation.
MP concerned
Elements of public (questions in the
expectation not House)
being met
Total loss of public
confidence
Business objectives/ Insignificant cost <5 per cent over 5–10 per cent over Non-compliance Incident leading >25
projects increase/ schedule project budget project budget with national 10–25 per cent over
slippage per cent over project budget
Schedule slippage Schedule slippage project budget
Schedule slippage
Schedule slippage
Key objectives not
Key objectives not met
met
Finance including Up to QR 250, 000 QR 250,000 to QR QR 1M to 5M loss QR 5M to QR 25M QR 25M+ loss or
claims loss or loss of 1M loss or loss of or loss of loss or loss of loss of opportunity
opportunity for opportunity for opportunity for opportunity for for income
income income income income
Non-delivery of key
objective/ Loss of
>1 per cent of
Purchasing failing to budget
pay on time
Failure to meet

1 2 3 4 5
specification/
slippage
Loss of contract /
payment by results
Service/business Loss/interruption of Loss/interruption Loss/interruption of Loss/interruption of Permanent loss of

interruption >1 hour of >8 hours >1 day >1 week service or facility
Environmental
impact Minimal or no Minor impact on Moderate impact on Major impact on Catastrophic impact
impact on the environment environment environment on environment
environment
Table 2 Likelihood score (L)

Likelihood score 1 2 3 4 5
Descriptor Rare Unlikely Possible Likely Almost certain
Frequency This will probably Do not expect it to Might happen or Will probably Will undoubtedly
How often might never happen/recur happen/recur but it recur occasionally happen/recur but it happen/recur,possibly
it/does it happen is possible it may do is not a persisting frequently
so issue
Table 3 Risk scoring = consequence x likelihood (C x L)
Likelihood
Likelihood score 1 2 3 4 5
Rare Unlikely Possible Likely Almost certain
Consequence
Score
5 Catastrophic 5 10 15 20 25
4 Major 4 8 12 16 20
3 Moderate 3 6 9 12 15
2 Minor 2 4 6 8 10
1 Negligible 1 2 3 4 5
For grading risk, the scores obtained from the risk matrix are assigned grades as follows:
1-3 Low risk (Action required within a month)

4-6 Moderate risk (Action required within a week)
8 - 12 High risk (Action required within 24 hours)
15 - 25 Extreme risk (Action Required immediately)


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POLICY/PROCEDURE

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

1.0 POLICY STATEMENT/PURPOSE:

2.1 Incident - An event or circumstance, which results in an unintended or unnecessary

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

2.8 Severity level 2, minor harm/damage: Events/error results in minor harm/damage

2.9 Severity level 3, moderate harm/damage: Events/error results in moderate

2.10 Severity level 4, serious harm/damage: Events/error results in serious harm/damage,

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

2.17 Risk Assessment Scoring Matrix - (See appendix B).

3.3.2 Note: Completing an OVA report is not an admission of liability; it is merely

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.5.4 Avoid recording opinions, judgments, conclusions, or derogatory remarks;

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.8 Responsibilities of Standard Users in the Electronic Incident Reporting System

3.8.1 An individual with Administrator rights is able to:

3.8.1.1 Create and submit files

3.8.2 An individual with File Manager A rights is able to:

3.8.2.1 Create and submit files

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.8.3 An individual with File Manager B rights is able to:

3.8.3.1 Create and submit files

3.8.4 The File Manager B of his/her assigned Unit/Section shall review,

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.8.4.2 The File Manager B of his/her assigned Department shall review,

3.8.5 An individual with Entry User rights is able to:

3.8.5.1 Create and submit files

3.9.1 Provide assistance and support to all Departments to customize the

3.9.2 Provide continuous educational awareness and workshop to the entire

3.9.4 Provide advice and support to all Departments to assist them in

3.9.5 Track and monitor progress of actions, recommendations for resolutions,

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.9.7.1 Severity level 1, 2 and 3 incidents should be managed locally (in

3.9.7.2 Actions taken to prevent recurrence and to promote patient safety

3.9.7.4 Severity level 4 (serious harm/damage) and Severity level 5

3.9.7.4.1 The management team and Health Information

3.9.7.4.2 Charts for all severity level 4 & 5 incidents should

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.13.1 Investigation Committee should be formed by the Hospital/Entity,

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.16 Care and Management of the Patients, Visitors and Staff

3.16.1 In the event of an occurrence, variance or accident (OVA), the Employee

3.16.2 If a visitor becomes ill or is injured on HMC premises, he or she should be

3.16.3.1 The report should be completed electronically by the injured staff

3.17 Handling of Equipment at Scene of Incident

3.17.1 If a piece of medical equipment or medical device is involved in the event,

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

3.18 Data Reporting

5.1 Occurrence. (2018) BusinessDictionary.com Retrieved April 03, 2018, from

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

6.0 TRACKING HISTORY OF CHANGES:

REVISION DATE: CHANGES:

SUBJECT MATTER EXPERT CONTRIBUTORS: None

REPORTING OF OCCURRENCES, ORIGINAL DATE: VERSION

7.1 Appendix A – OVA Reporting Process Map

7.2 Appendix B – Risk Assessment Matrix

Consequence score (severity levels) and examples of descriptors

Quality/complaints/a Peripheral element Overall treatment Treatment or Non-compliance Totally

Consequence score (severity levels) and examples of descriptors

Poor staff Very low staff No staff attending

Low performance Zero performance

Critical report Severely critical

Consequence score (severity levels) and examples of descriptors

Service/business Loss/interruption of Loss/interruption Loss/interruption of Loss/interruption of Permanent loss of