OVR MANAGEMENT & RISK REGISTER

PATIENT SAFETY

By:
Dr. Muna Bhutta
Head of Patient Safety & Risk Management

1
 ‫‪OVR Management‬‬
‫تــ حـوادث لاـحيـود‬
‫اـريقـرـ‬ ‫إدـارة‬

‫‪2‬‬
 Event
Occur/Discovered

Mitigate the Harm

Fill the OVR Form If near miss staff can fill anonymous
report and send directly to risk
management

Forward to direct
Manager

3
 Unit Manager

One Copy to the

Send OVR to responding
risk unit in the
copy is kept with dept.
QPS
initiating Dep)

4
 Risk manager
receive the OVR
copy

Track the OVR in

the Data base

Determine actual
severity and
likelihood

OVR in Green OVR in Yellow OVR in amber OVR in amber

Zone Should be Zone Should be Zone Should be Zone Should be
closed within 5 closed within 10 closed within 10 closed within 14
working days working days working days working days
5
 Risk manager
sends response to
initiating
department

Initiator receive
and sign off

Send back to RM
OVR Pathway
Analyzing the Incident:

1. Category.
2. Harm Level.
3. Likelihood.
4. Risk Level.

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 Category of Incident (29)

1. Infection Control Related Issues 8. Communication Issues

2. Occupational Health 9. Falls
3. Housekeeping 10. Radiation treatment.
4. Intravenous 11. Labor and Delivery related issues.
5. Pressure Ulcer(Injury) 12. Supply Chain issues (logistics).
6. Skin Lesion Integrity 13. Laundry services
7. Medication 14. Sentinel Events

9
 Category of Incident (29)
15. Security Related Issues 23. Environment / Safety
16. Behavior 24. Accommodation related Issues
17. Staff related Issues 25. Information Technology Related Issues
18. Patient Care Management 26. Medical Imaging and Diagnostic
19. Laboratory Related Issues Procedures
20. Procedural 27. Food Service
21. Medical Equipment Issues 28. Clinical Nutrition
22. Facility Maintenance 29. ID/Document/Consent

10
Patient Care Management:

• Delay in admission.
• Delay in discharge.
• Delay in Transfer.

11
Impact Score (severity levels) with scores, descriptors and example
definitions
Score 1 2 3 4 5
Descriptor Negligible Minor Moderate Major Catastrophic

Impact on the Minimal Injury Minor Injury or Moderate Major injury Incident leading
safety of the requiring no or illness, requiring injury leading to long to death
patient, staff or minimal minor requiring term incapacity or  
public (physical intervention or intervention professional disability
or psychological treatment No  
Increase in length intervention
harm) time off work of hospital stay Increase in
(employee) by 1-3 days length of
hospital stay
by 4-15 days

12
 Practice:

• Needle Stick Injury No transmission of disease.

1
• Patient Fall without Injury. 1

• Patient fell down in the toilet and

died from head injury resulting from the fall. 5
13
 Prevented,
NO HARM not impacted on
patient
C a t ch
LOW Good

MODERAT
Harm Not prevented,
E
but resulted in
no harm
SEVERE L uc k!
Good

DEATH

14
Likelihood ‫إلحتماـهـ‬
‫ اـ لي‬:
– The probability of an event is the measure of the
chance that the event will occur as a result of an
experiment.

15
Likelihood “time-frame-based” scores with descriptors and example definitions
Score 1 2 3 4 5
Descriptor Rare Unlikely Possible Likely Almost
‫نادر الحدوث‬ ‫غيـ محتمل‬
‫ر‬ ‫محتمل‬ ‫ عالي اإلحتمالية‬Certain
‫الحدوث‬ ‫الحدوث‬ ‫أكيد‬
Frequency: This will We don’t expect It might happen It will probably It will
General probably never it to happen or or recur happen or recur undoubtedly
description happen or recur recur but it is occasionally but it is not happen or recur,
possible it may persisting issue possibly
do so frequently.

Frequency: Never expected Expected to Expected to Expected to Expected to

“Time frame- to occur for occur at least occur at least occur at least occur at least
based” years annually monthly weekly daily

Probability: Less than 0.1% 0.1-1% chance 1-10% chance 10-50% chance Greater than
Will the risk chance the risk the risk will the risk will the risk will 50% the risk will
occur or not? will occur occur occur occur occur

16
 Examples:
• Birth trauma :
– 2  per 1000 deliveries.
– What is the probability then????
– Unlikely.

17
 Level of Risk

• X – Extreme.
• High.
• Medium.
• Low Risk.

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• The level of risk is its magnitude. It is estimated by
considering and combining consequences and
likelihoods.

19
 Example: Adverse drug reaction leading
to death
  Likelihood
1 2 3 4 5
Impact Scores Rare Unlikely Possible Likely Almost
certain
5 Catastrophic 5 10 15 20 25
4 Major 4 8 12 6 20
3 Moderate 3 6 9 12 15
2 Minor 2 4 6 8 10
1 Negligible 1 2 3 4 5

20
 Example: patient fall resulting in no
harm
  Likelihood
1 2 3 4 5
Impact Scores Rare Unlikely Possible Likely Almost
certain
5 Catastrophic 5 10 15 20 25
4 Major 4 8 12 6 20
3 Moderate 3 6 9 12 15
2 Minor 2 4 6 8 10
1 Negligible 1 2 3 4 5
21
Risk Rating Risk evaluation descriptor Suggested action

1-3 Low risk Maintain existing control

4-6 Moderate risk Review existing control

8-12 High risk Improve existing control

15-25 Extreme risk Improve existing control

measures immediately

22
Types of Controls Examples
Elimination of the
Preventive
source of Hazard.
Reducing Exposure to
Corrective Hazard such as Job
rotation.

Directive Training and guidelines.

Monitoring through
Detectives
surveillance.
 Incident Level of investigation required
Grading/ Type  
Green (Low) These incidents generally require minimum investigation that can be undertaken adequately by the
ward/departmental manager. However, they must be monitored regularly to identify patterns or trends and,
when necessary, develop and implement actions.
 
It is acceptable for the ward/departmental manager to close such incidents following investigation and
recording of findings and lessons learned on electronic reporting system or OVR database (if paper system is
used). Investigation of this grade of incident should normally be completed and closed within 5 working
days.

Yellow (Medium) These incidents generally require minimum investigation that can be undertaken adequately by the
ward/departmental manager. However, they must be monitored regularly to identify patterns or trends and,
when necessary, develop and implement actions.
 
It is acceptable for the ward/departmental manager to close such incidents following investigation and
recording of findings and lessons learned on electronic reporting system or OVR database (if paper system is
used). Investigation of this grade of incident should normally be completed and closed within 10 working
days.

24
Amber (High) The degree of seriousness of these incidents may require multidisciplinary or independent investigation.
The Head of Service/General Manager for the area where incident occurred is responsible for ensuring an
appropriate level of investigation is conducted, formal recording and dissemination of findings, actions
taken, lessons learned and closure of these incidents. Where necessary advice can be taken from the
DQPS or RM. Investigation of this grade of incident should normally be completed and closed within 10
working days.

Red (Extreme) The Hospital/organization director is responsible for ensuring that a thorough investigation is undertaken.
The organization Director will agree with the Director Quality and Safety and Risk Manager whether a
Root Cause Analysis is required and will appoint a lead investigating officer (who is appropriately
trained),. The Risk Management Department maintains a list of staff trained in Root Cause Analysis.
 
Investigation of this grade of incident should, when possible, be completed within 14 working days.
Closure or down-grading of red incidents requires approval by the DQPS, who, in conjunction with the
RM, will review investigation/closure of red incidents monthly.

25
Post-partum hemorrhage > 1,000ml ,
patient needed blood transfusion and
admitted 2 days more.
Category Labor and Delivery related issues

Harm Minor 2
Likelihood Possible 3
Risk Level Moderate Risk 6

26
Primigravida Patient death during CS

Category Sentinel Event

Harm Catastrophic 5
Likelihood Unlikely 2
Risk Level High Risk 10

Record in the risk register 27

 Near Miss
Nearmiss– an event or situation that could have resulted in
an adverse event that caused patient harm but didn’t reach
the patient either by change or through timely
intervention.
 
• Banana served to a patient who is allergic to banana, patient informed the nurse the try returned to food
service (patient did not eat it).

• Wrong medication received from pharmacy, nurse returned it before administering the drug to the patient.

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 PATIENT SAFETY
Patient safety : The degree to which harm is minimized to the patient, staff , visitor.

Adverse Event
•An untoward, undesirable, and usually unanticipated event involving patient, staff or a visitor.

-Patient fall
- Improper administration of medications
- Stroke resulting from inadequate treatment 0f hypertension or a preventable hospital admission
• Minor Adverse Event – an event that has a potential to cause or has caused insignificant harm to
patient/staff/visitor.  

• Moderate Adverse Event – an event that causes reversible patient/staff/visitor harm requiring transfer to
a higher level of care or requiring more frequent monitoring. 

• Major Adverse Event – an event that lead to a patient with permanent decrease of body functions
(Physical or intellectual) unrelated to natural course of the illness and leading to the increase length of stay
or additional operations or procedures.
Sentinel Event
  Sentinel Event An unexpected occurrence leading to patient death or serious harm and is caused by health care rather than
patient’s underlying illness.

– Infant abduction or discharge to the wrong family.

– Patient suicide/ homicide in hospital.

– Rape of a patient, staff or visitor.

– Significant hemolytic transfusion reaction involving administration of blood or blood products having major blood
group incompatibilities.

– Surgery on the wrong patient or body part.

– Significant Medication Errors / Adverse drug reaction leading to death or permanent loss of function.

– Retained instrument or swab

– Patient fall leading to death or permanent loss of function.

 SENTINAL EVENTS IN 2017-18
SENTINEL EVENTS…
1.Pt death in OR (ortho case with Massive PE)
2.Hemodialyis in wrong pt

3.Maternal death(embolism/septic shock)

4.Unexpected pt death (Trauma)

5. Stillbirth

6. Rt hand gangrene newborn

 Sentinel Event

Process to follow :

Submit an occurrence variance report as soon as

possible

The department head notifies Medical Director and

Hospital Supervisor General and will submit detailed

report to Medical Director Office and OVR within

24 hours
Medical Director will inform the TQM Director and Head
of Risk Management and will submit the report to the
Head of Risk Management.
35
Mandatory Reportable Events includes the following events:
1.3rd or 4th degree perineal tear post-delivery
2.Erb's palsy
3.Eclampsia in a booked patient
4.Missing Vaginal swab in female patient
5.APGAR Score 5 in 10 minutes
6.Hypoxic encephalopathy in a new born
7.Unexpected unplanned return to operating room
8.Unplanned blood transfusion
9.Unscheduled return to emergency room after discharge from the ward (within 72 hours)
10.Wrong implant or prosthesis
11.Injury or unplanned repair or removal of an organ
12.Uterine Rupture
13.ROP needing laser or Cryotherapy
14.IVH grade III/IV
15.Injury to Common Bile Duct During Laparoscopic Cholecystectomy
16.Maternal ICU admission
17.Still Birth
18.Therapeutic Abortion
19.Septic Abortion
20.Venous thromboembolism
36
CBAHI STANDARD

Patients receive response when involved in significant

events and this should be documented in patient medical
records.

37
DEPARTMENTAL RISK REGISTER

38
 ‫إدارة الجودة وسالمة المرضى وحدة المخاطر وسالمة المرضى‬
‫تقرير المخاطر النصف سنوي لعام ‪2018‬‬
‫‪ 1‬يناير ‪ 30 -‬يونيو ‪2018‬م إدارة الجودة وسالمة المرضى‬
‫أسم المنشأة ‪...............................................................‬‬

‫‪Risk‬‬ ‫‪Submitting‬‬
‫‪ Likelihood - Impact -‬وصف‪ Risk Description -‬ن??وع ‪Unit/Departme Risk Type -‬‬ ‫‪Overall‬‬ ‫‪Action Owner Expected Action‬‬
‫‪Index -‬‬ ‫‪Required Action -‬‬ ‫‪Completion Date-‬‬
‫‪Rating -‬‬ ‫ا??لمسؤول عن‪-‬‬
‫ا??لرق?م?‬ ‫ا ?إلدارة ‪nt - -‬‬ ‫ا??لخطر‬ ‫ا??لخطر‬ ‫ا??إلحتما??لية‬ ‫ا ?ألثر‬ ‫ا??إلجراء ا??لمطلوب‬ ‫ا??لتاريخ ا??لمتوقع? إل?كتما??ل‬
‫ا??لتقييم? ا??لع?ام?‬ ‫ا??إلجراء‬
‫ا??لتسلسلي‬ ‫ا??لقسم?‬ ‫ا??إلجراء‬

‫‪1‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪2‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪3‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪4‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪5‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪6‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪7‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪8‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪9‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
‫‪10‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪0‬‬ ‫‪ ‬‬ ‫‪ ‬‬ ‫‪ ‬‬
Risk Category Explanation / Examples
Financial Risks insufficient funds.

Operational/Clinical Risks OR delay , inappropiate VTE prophylaxis

Human Capital Absenteeism, inadequate staffing

Strategic Risks Risks that can impact organization development and delivery of its strategic
objectives. Media releases losing public trust and underutilization of service, loss of reputation

Legal/Compliance Risks violation of law,patient complaints

Technology Risks OASIS , bar coding issues

Natural Disaster/Hazard Fire extinguishers not working

 Risk Review
Low risks should be reviewed at least annually.

Medium should be reviewed at least biannually.

High risks must be reviewed at least quarterly.

Extreme risks must be reviewed at least monthly.

MID-YEAR RISK ASSESSMENT
REPORT 2018
(Top 5 Risks)
 TOP 1
Non-compliance to VTE assessment , appropriate prophylaxis dose and Risk Description
duration

Level: 20 (Extreme) Impact: 5 Likelihood: 4 Risk Assessment

HODs Internal Medicine/ General Surgery/ Orthopedics/ Ob-Gyne :Risk Owner

− Ensure strict adherence to VTE guidelines Recommended
− Follow VTE indicators/ KPI. Action
− Follow feedback from GDHAR.

Head of Departments /Medical Director/VTE Champion Action Owners

⃝ Board. Need Escalation
⃝ Health Directorate.
⃝ Ministry of Health Headquarters.
TOP 2
Lack of Proper Communication / Endorsement Risk Description
Level: 20 (Extreme) Impact: 5 Likelihood: 4 Risk Assessment
HODs All Medical Departments :Risk Owner
− Ensure compliance to Multidisciplinary Plan of Care form/policy Recommended
− Endorsement Sheets to be completed each shift Action
− SBAR each shift
− Provision of Bleeps to easy communication between treating staff

HODs/Medical Director/ Hospital Director Action Owners

 Board. Need Escalation

⃝ Health Directorate.
⃝ Ministry of Health Headquarters.
TOP 3
Insufficient Critical Care Services (ICU/ PICU Risk Description
Level: 20 (Extreme) Impact: 5 Likelihood: 4 Risk Assessment

.HOD Pediatric Dept. / ICU :Risk Owner

− Training of staff in higher centers for better care of pediatric patient Recommended
in PICU. Action
− ICU extension project to be followed
− Provision of adequate equipments (E.g., Central Monitor, EEG, U/S ,
CRRT fluid)

HOD Pediatrics/ HOD ICU/ Medical Director/ Hospital Director Action Owners

 Board. Need Escalation

⃝ Health Directorate.
 Ministry of Health Headquarters.
TOP 4
Nursing / Allied Staff Absenteeism Risk Description
Level: 20 (Extreme) Impact: 5 Likelihood: 4 Risk Assessment

HOD ICU/ Director of Nursing / HOD ER/ HOD OPD/ HOD Respiratory :Risk Owner
therapy/ HOD Radiology department

− Strict disciplinary action in case of absenteeism. Recommended

− Recommends modifications to the regulation of absenteeism. Action
− Referral to Motaba.

Director of Nursing/ Medical Director/HODs Action Owners

 Board. Need Escalation
⃝ Health Directorate.
⃝ Ministry of Health Headquarters.
TOP 5
Lack of Security/ Safety Risk Description

Level: 15 (Extreme) Impact: 3 Likelihood: 5 Risk Assessment

HOD Pediatrics/ ER/ ICU/ Maintenance Service :Risk Owner

− Increase in safety & security staff. Recommended

− Ensure and increase camera surveillance. Action

HOD Safety & Security/ Hospital Director Action Owners

 Board. Need Escalation

⃝ Health Directorate.
⃝ Ministry of Health Headquarters.
 PATIENT SAFETY CULTURE SURVEY

• Conducted Dec 17 ,2017

done again in Dec , 2018

48
SIGNIFICANT FINDINGS DISCUSSED WITH
ACTIONS IN PLACE
1. Staffing.
2. Non punitive Response to Errors & No. of
events reported.
3. Handoffs & Transitions
4. Overall Perceptions of Patient Safety
5. Supervisor/Manager Expectations & Actions
Promoting Patient Safety.
6. Communication Openness.
 Communication Openness
 Teaching and
encouraging staff to
use CUS & TWO
challenge rule.
 TWO challenge rule...
"Dr. Smith do you really want me to give Phenergan with
codeine to this 3 month old in room 2?”

The physician in a hurry and on the fly retorts "Yes, that is my

order."

The nurse would challenge a second time "Dr. Smith do you

REALLY want me to give Phenergan with codeine to a newborn
who might stop breathing???"

The physician usually is giving his attention now! "No, I want

the toddler who is coughing and vomiting in room five to have
that medication!!"
THANK YOU