‫الصح السادس‬

‫ي‬ ‫النطاق‬

RISK MANAGEMENT IN HEALTHCARE

AGENDA
▪ Occurrence Variance Report – OVR

▪ Sentinel Events
PURPOSE

❖ To provide a systematic, standardized hospital wide

mechanism to identify events and develop prevention
/improvement programs.

❖ To plan and implement a corrective measures through

identification by root cause analysis (RCA).
Definitions:

Occurrence: an event that occurs which is unusual to normal

events.

Variance: something that occurs that is different from the

standard/policy/expected procedure or outcome.

Occurrence Variance Report (OVR): an internal form used to

document the details of the occurrence/event and the
investigation of an occurrence, and the corrective actions
taken.
TYPE OF EVENTS

❑SENTINEL EVENT - an unexpected occurrence

involving death, serious physical or psychological
injury.
❑ADVERSE EVENT - is an undesired harmful effect
resulting from a medication or other intervention such
as surgery.
❑NEAR MISS- is an action or condition that has the
potential to cause an adverse event such as injury,
damage, loss or harm, or risk to equipment, materials
of patients but fails to do so by chance.
❑RISK BEHAVIORS- any occurrence or circumstance that
deviates from established standards of care.
WHAT SHOULD BE REPORTED?

▪ Occurrences not consistent with routine operation of

facility and /or adversely affects, threatens the health or

life of patient, visitor, employee, student or volunteer.
WHO SHOULD
REPORT?

ANYONE
(WHO DISCOVER
OR WITNESS AN
OCCURRENCE )
 WHAT TO REPORT ?

EXAMPLES:

Security problem Violation in standard precaution

Wrong procedure in any area Delays in:_______
Wrong patient, surgery Non-availability of supplies/forms
Lost specimen Expired blood
Missing files Wrong patient identification
Charting error Wrong drug, dose, route,
No response mislabelled
No order Needle stick injury
Pressure ulcer Others…….
Patient fall
 ▪ All OVR are confidential documents
and shall only be handled by
authorized professionals.
▪ Should not be duplicated,
exception of QMPS.
▪ Should not be used against staff
EXCEPT in extreme situations
(reckless behavior / patient harm).
CONFIDENTIALITY ▪ Hospital staff shall refrain from
discussing the content of OVR.
▪ Discussion of general issues on
OVR can be used for corrective /
educational purposes.
▪ Complete the OVR form in a clear
legible handwriting use blue /black
ink.
OCCURRENCE VARIANCE REPORT
(OVR) CONSIST THE FOLLOWING :
▪ Occurrence details filled by whoever witnessed or
attended or discovered the occurrence.
▪ Occurrence details.
▪ Person/s affected.
▪ Brief description of occurrence.
▪ time /date of occurrence.
▪ Actions taken to stabilize the affected individual/s.
THEN…

▪ Completed by immediate supervisor. (if

applicable/available).
▪ Immediate action taken to protect the affected individual/s.
▪ If physician was notified ,he should write a brief statement
of the condition of the affected individual/s and what has
been done.
▪ Forward to QMPS within Max 72 hours. (preferably
immediately).
▪ Risk manager to evaluate the occurrence if sentinel or not.
▪ If sentinel event, follow sentinel event procedure.
THEN…

▪ Risk manager to validate and investigate the occurrence.

▪ Follow up of Corrective action, recommendation to prevent the
recurrence of event to be filled by QMPS to record the OVR in log
sheet.
▪ If the occurrence happened after working hours should to submit
to head of department next day to validate and submit it to
QMPS.
▪ During weekend the OVR shall be submitted to immediate
supervisor and all efforts shall be taken to protect affected
individual/s. OVRs to be submitted to QMPS on the first working
day.
▪ Sentinel events shall be dealt with immediately. No delay shall be
ever practiced. Risk manager shall be notified with no hesitation.
OVR FLOW CHART
OVR FORM
SENTINEL EVENTS
▪ 1. Abduction of any patient receiving care within a healthcare
facility
▪ 2. Discharge of an infant to the wrong family
▪ 3. Discharge of a Minor or Incapacitated Patient to an
unauthorized person
▪ 4. Maternal death, permanent harm, or severe, temporary harm
▪ 5. Suicide, attempted suicide, or self-harm that results in severe,
temporary harm, permanent harm, or death while being cared
for in a healthcare setting or within 72 hours of discharge,
including the emergency department
▪ 6. Surgery/invasive procedures performed at the wrong site, on
the wrong patient, or the wrong procedure.
SENTINEL EVENTS

▪ 7. Administration of incompatible ABO, Non-ABO of blood/ blood

products, or transplantation of incompatible organs
▪ 8. Unintended retention of a foreign object in a patient after
surgical/invasive procedure
▪ 9. Unanticipated death of a “term” infant
▪ 10. Rape leading to death, permanent harm, or severe, temporary
harm of a patient, staff member, licensed independent
practitioner, visitor, or vendor while on-site at the healthcare
facility
▪ 11. Assault leading to death, permanent harm, or severe,
temporary harm, or homicide of a patient, staff member, licensed
independent practitioner, visitor, or vendor while onsite at the
healthcare facility.
SENTINEL EVENTS

▪ 12. Fire, flame, or unanticipated smoke, or flashes occurring

within a healthcare facility
▪ 13. Unauthorized Departure of the patient (absconded) while on
care from the healthcare facility that resulted in death, permanent
harm, or severe temporary harm
▪ 14. Medication error leading to death, permanent, or severe
temporary harm
▪ 15. Patient death, permanent, or severe temporary harm
associated with intravascular air embolism
▪ 16. Patient death, permanent, or severe temporary harm as a
result of medical device breakdown or failure when in use
▪ 17. The unexpected collapse of any building within a healthcare
facility
SENTINEL EVENTS

▪ 18. Transfusing/transplantation of contaminated blood, blood

products, organ or tissue
▪ 19. Death or serious disability associated with failure to
manage/identify neonatal hyperbilirubinemia
▪ 20. Delivery of radiotherapy to the wrong body region or dose
exceeds more than 25% of the total planned radiotherapy
dose.
▪ 21. Any (Stage 3, 4 or unstageable) Healthcare facility-
acquired pressure injury (ulcer)
▪ 22. Unexpected death, permanent or severe temporary harm
associated with transport/transfer of patients
SENTINEL EVENTS

▪ 23. Patient death, permanent harm, or severe temporary harm as

a result of patient fall
▪ 24. Patient death, permanent harm, or severe temporary harm
associated with wrong administration/connection of medical gas.
▪ 25. Transmission of disease as a result of using contaminated
instruments or equipment provided by the healthcare facility.
▪ 26. Death, permanent, or severe temporary harm associated with
the use of incorrectly positioned Oro – or Nasogastric tube.
▪ 27. Accidental burn of second degree and above during patient
care.
 “Be Safe”

“Safe Practice”

“Act responsibly”

“Enhance reporting Culture”