Opportunity for Improvement Reporting

1. Any injuries regardless of severity to patients, staff visitors, volunteers, and vendors.

2. Any damages to or loss of personal/hospital property.

3. Variations from established policies and procedures regardless of whether personal injury or property loss is involved. Policy and procedure variation can be related to medication dispensing and administration, diagnostic and therapeutic procedures, interruption of a support service (heating/cooling, food service, linen, etc.).

4. Any unexpected clinical complication, regardless of whether a policy or procedure variance is involved, that may result in additional care or observation or prolonged care or surgery.

5. Any medication Occurrences , such events may be related to professional practice, health care products, procedures, and systems including prescribing, order communication labeling /packaging, compounding, and dispensing, distribution, administration, education and use.

6. Any potential safety hazard that may be related to medical devices and/or products or environmental hazards should be reported. This potential safety hazards may include.

7. Occurrences-is any events or incident that is not consistent with the policy and procedure of the organization, this events or incident includes variances, near miss, adverse events and sentinel events.

8. Near Miss-is used to describe any process variation that did not affect an outcome but for which a recurrence carries a significant chance of a serious adverse outcome. Such a “near miss” falls within the scope of the definition of a Sentinel/Critical Event but outside the scope of those Sentinel/Critical Events that are subject to review by the Joint Commission under its Sentinel/Critical Event Policy.

9. Adverse Event-are unexpected occurrences, therapeutic misadventures, iatrogenic injuries or other adverse occurrences directly associated with care or services provided. Adverse events can be categorized as either a sentinel event or near miss that results from acts of commission or omission (e.g. administration of the wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention, adverse reactions or negative outcomes of treatment, etc.), examples of adverse events include: patient falls, medication errors, procedural errors/complications, completed suicides, para suicidal behaviors (attempts/gestures/threats), and missing patient events.

A sentinel event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient and results in any of the following:

a) Death

b) Permanent harm

c) Severe temporary harm

Severe temporary harm is defined as critical, potentially life-threatening harm lasting for a limited time with no permanent residual but requires transfer to a higher level of care/monitoring for a prolonged

period of time, transfer to a higher level of care for a life-threatening condition, or additional major surgery, procedure, or treatment to resolve the condition. An event is also considered sentinel if it is one of the following:

d) Suicide of any patient receiving care, treatment, and services in a staffed around-the-clock care setting or within 72 hours of discharge, including from the hospital’s emergency department (ED)

e) Unanticipated death of a full-term infant

f) Discharge of an infant to the wrong family

g) Abduction of any patient receiving care, treatment, and services

h) Any elopement (that is, unauthorized departure) of a patient from a staffed around-the-clock care setting (including the ED), leading to death, permanent harm, or severe temporary harm to the patient

i) Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups)

j) Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of any patient receiving care, treatment, and services while on site at the hospital

k) Rape, assault (leading to death, permanent harm, or severe temporary harm), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the hospital (Also see SQE.8.2)

l) Invasive procedure, including surgery, on the wrong patient, at the wrong site, or that is the wrong (unintended) procedure

m) Unintended retention of a foreign object in a patient after an invasive procedure, including surgery

n) Severe neonatal hyperbilirubinemia (bilirubin > 30 milligrams/deciliter)

o) Prolonged fluoroscopy with cumulative dose > 1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or > 25% above the planned radiotherapy dose

p) Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient care

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

r) Severe maternal morbidity (not primarily related to the natural course of the patient’s illness or underlying condition) when it reaches a patient and results in permanent harm or severe temporary harm