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misses allows learning opportunity and quality improvement action Although health care organizations have expended substantial effort to promote incident reporting, studies suggest that underreporting is pervasive. Many observers attribute underreporting to the punitive (“name and blame”) approach that many health care organizations have taken with regard to safety incidents. By indoctrinating a sense of fear, the punitive approach discourages reporting and, in doing so, prevents organizational learning and improvement. Obtaining the information offered through reporting is considered crucial for identifying risky situations, analyzing underlying causes, taking corrective action, and implementing prevention efforts. Those directly involved in patient care are said to possess important safety related information that cannot be obtained through retrospective peer review or computerized surveillance systems (Leape, 2009). Slide 119 GOAL OF REPORTING PREVENT REOCCURRENCE REMEMBER--The goal of reporting medical errors is to analyze the occurrence and identify methods for preventing reoccurrence. 65 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 120 JUST CULTURE Completion of incident reports is the expectation associated with occurrence of unusual events. To make incident reporting work, safety experts contend, health care organizations must establish a “just” culture—that is, an organizational context in which health professionals feel assured that they will receive fair treatment when they report safety incidents. A just culture has been defined as a “non-punitive” environment in which individuals can report errors or close calls without fear of reprimand, rebuke, or reprisal. At the same time, a just culture is not an environment wherein no accountability exists. Failing to discipline those who commit unsafe acts due to incompetence or recklessness is just as much a violation of widely accepted moral principles as is punishing those who commit honest mistakes (Leape, 2009). Slide 121 FLORIDA DEPARTMENT OF HEALTH: INTERNAL REPORTING Florida Department of Health (DOH) Policy # 385-OD26-09 provides guidelines for reporting incidents as defined in DOH #5-6-08 Policy and Procedures on Incident Reporting Florida Department of Health (DOH) Policy provides guidelines for which employees are expected to report incidents as defined in DOH Policy and Procedures on Incident Reporting. 66 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 122 INTERNAL REPORTING CATEGORY I INCIDENT Does not involve serious injury, property damage, litigation or outbreak ‒ Report to manager as soon as possible but no later than 5:00 p.m. the next workday ‒ Complete Initial Incident Report Form DH 1152 (print or online) The employee(s) that were involved or were a witness to the incident should report the incident to the appropriate manager as soon as possible and no later than 5:00 p.m. the next workday. Even if the incident is promptly resolved, management and the Director’s Office must be notified of the incident and the status. The reporting employee(s) must complete the Initial Incident Report Form DH 1152 Examples of ‘Category One’ incidents are: • Non-serious accident/injury/illness: slips, trips, falls, etc.; • Medication/Dispensing error without adverse consequence; • Unintentional breach/violation of confidential information or patient privacy with no reasonable expectation of harm. Slide 123 INTERNAL REPORTING CATEGORY II INCIDENT Serious incident which presents injury, property damage, potential for litigation or disease outbreak ‒ Report to manager immediately ‒ Complete Initial Incident Report Form DH 1152 (print or online) ‒ Review by the Office of the Inspector General A Category Two incident is an incident of a more serious nature which must be sent to the Office of the Inspector General. Following approval by the appropriate parties at the local level, it must be encrypted and emailed to the IG via email account. Examples of Category Two incidents are: • Alleged abuse/neglect; • Major dispute/altercation/fighting; • Serious accident/injury/illness; • Introduction of contraband/drugs/alcohol; • Medication/Dispensing error with adverse consequences; • Death, disability, or serious injury/illness of any client, patient, visitor, or other individual thought to 67 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide be a result of being provided or withheld health services or otherwise occurring on DOH property; • Unauthorized transfer of bodily fluids; • Unintentional breach/violation of confidential information or patient privacy or unintentional if reasonable expectation of harm towards a person exists. Unavailable or unknown information relevant to the occurrence should not be a reason to delay timely submission of an Incident Report. Unavailable/unknown information can be submitted later once it is known. Slide 124 FLORIDA LAW EXTERNAL REPORTING Florida Statute 395.0197 mandates reporting of any adverse event which occurs within a healthcare organization. Florida Statute 395.0197 mandates reporting of any adverse event which occurs within a healthcare organization. According to the statute, the definition of an “adverse incident” is “an event over which health care personnel could exercise control and which is associated in whole or in part with medical intervention, rather than the condition for which such intervention occurred” (Fla. Stat. 395.0197 (5)). 68 It's a New Day in Public Health FDOH Medical Errors: A Public Health Perspective Learner Course Guide Slide 125 FLORIDA LAW ADVERSE INCIDENTS ‒ Death ‒ Brain or spinal damage ‒ Permanent disfigurement ‒ Fracture or dislocation of bones or joints There are a number of injuries which are considered “adverse events” • Death; • Brain or spinal damage; • Permanent disfigurement; • Fracture or dislocation of bones or joints; Slide 126 FLORIDA LAW ADVERSE INCIDENTS ‒ Limitation of neurological, physical or sensory function which continues after release ‒ A condition requiring specialized medical attention or surgical intervention which results from non-emergent medical intervention for which the patient has not given informed consent ‒ A condition which requires the transfer of the patient to a unit providing a higher level of acute care as a result of the adverse event rather than the patient’s condition prior to the adverse incident (continued) • Limitation of neurological, physical or sensory function which continues after release; • A condition requiring specialized medical attention or surgical intervention which results from nonemergent medical intervention for which the patient has not given informed consent; • A condition which requires the transfer of the patient to a unit providing a higher level of acute care as a result of the adverse event rather than the patient’s condition prior to the adverse incident. All adverse incident reports must be filed with the organization’s internal risk management system within 3 days of the occurrence of the event. Designated organizational officials must then report the event to the Florida Agency for Health Care Administration (AHCA) in two types of reports: • Code 15 Report - offers detailed report of serious patient injuries, the organization’s investigation of the injury and determination of if the factors causing or resulting in the adverse incident represents potential risk to other patients. A Code 15 report must be filed within 15 calendar days of the occurrence of the adverse incident; • Annual Report - contains a summary of all adverse incidents and malpractice actions (new, pending and closed) which occurred in the organization during the course of the calendar year. Slide 128 OPPORTUNITY Medical error reporting offers the opportunity to examine the system and correct that aspect which contributed to error or near miss in order to prevent recurrence. No matter the medical error one makes, it is