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state requires a patient safety officer and committee, Medicare does not. However, the goal of integrating patient safety, risk management, infection control, quality assurance, and performance improvement are essentially part of the state and Medicare surgical center regulations. CORRECT PATIENT, CORRECT PROCEDURE, CORRECT SITE PROCEDURES The organization must develop, implement and have an ongoing evaluation of the procedures, protocols, and systems to accurately identify patients, planned procedures, and the correct site of the planned procedure, availability of correct implant in order to minimize these types of occurrences. See the appendices to review Chapter 64B -8-9.007 FAC, Standards of Practice for Medical Doctors, regarding the physician’s responsibility. The State requires that an incident be reported to the licensed healthcare risk manager or the risk manager designee within 3 business days after the occurrence. The first paragraph of the following guide, first published by AHCA, is critical to the decision of whether an incident meets or does not meet the definition of adverse. Was the incident something over which health care personnel could exercise control? Gathering of information, in some cases including peer review, will be necessary to make that determination. Note that there is not a time limit from the date of service to the patient to the date of an adverse incident. For example, a patient could die or be admitted for additional surgery weeks after an infection caused by improper sterilization of instruments or a retained foreign object. The health care personnel would have had control over instrument sterilization and over a process to assure a foreign object was not retained. It is important to note that if an adverse incident occurred prior to admission, the facility providing patient care due to the adverse incident is required to report the adverse incident. An example would be a hospital reporting a patient admitted from a surgery center due to a medication error occurring at the surgery center. The term “adverse incident” means 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, and which results in one of the following injuries: oo A resulting limitation of neurological, physical, or sensory function which continues after discharge from the facility Any condition that required specialized medical atten-tion or surgical intervention resulting from non-emergency medical intervention, other than an emergency medical condition, to which the patient has not given his or her informed consent Any condition that required the transfer of the patient, within or outside the facility, to a unit providing a more acute level of care due to the adverse incident, rather than the patient’s condition prior to the adverse incident. The performance of a surgical procedure on the wrong patient. The performance of a wrong surgical procedure oo The performance of a wrong-site surgical procedure The performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patient’s diagnosis or medical condition The surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage was not a recognized specific risk, as disclosed to the patient and documented through the informed-consent process The performance of procedures to remove unplanned foreign objects remaining from a surgical procedure The performance of a surgical procedure on the wrong patient The performance of a wrong-site surgical procedure oo The performance of a wrong surgical procedure The performance of a surgical procedure that is medically unnecessary or otherwise unrelated to the patient’s diagnosis or medical condition The surgical repair of damage resulting to a patient from a planned surgical procedure, where the damage is not a recognized specific risk, as disclosed to the patient and documented through the informed-con-sent process The performance of procedures to remove unplanned foreign objects remaining from a surgical procedure Any of the above incidents, whether occurring in the licensed facility or arising from health care prior to admission in the licensed facility shall be reported to the AHCA. Obtain copy of the risk manager’s license and place with risk manager’s agreement. If the risk manager and/or risk manager designee is an employee, place the risk manager and risk manager designee’s job descriptions in their individual employee files. If the risk manager is contracted, place a copy of the license with the agreement for services. Document appointment of risk manager and risk manager designee in board minutes and include re-appointment annually which will make the board action easier to locate when there is a survey. Review incident/occurrence report forms to ensure that all data fields required by the state are included on the form and are completed. Check that the risk manager or risk manager designee has received the incident/occurrence reports within three business days of the incident. If this is not occurring, review reasons and implement changes. This shall be documented by the risk manager or risk manager designee signing and dating the receipt of the report. Document attendance at risk management education and training and keep in a file or notebook for review during an inspection. All employees including full time, part-time, PRN, contract agency staff, and allied health professionals are to have risk management education and training. The facility should maintain a copy of the education and training program that is presented to staff to fulfill the regulatory requirements. Education and training should include at least (1) The operation and responsibilities of the incident reporting system; (2) timely and accurate reporting of incidents (HOW, WHAT, WHEN, WHY, WHERE);(3) the state definition of an adverse incident and reporting requirements; (4) staff duty to report allegations of patient sexual misconduct/abuse; (5) two-person requirement in recovery room; (6) duty to notify patients of an adverse incident; (7) risk management and risk prevention education; (8) purpose and function of risk management and patient safety programs. Track and trend all incident reports. Develop categories to identify problem areas. Tracking and trending can assist in highlighting frequency and severity of incidents. It can help call to attention opportunities to improve processes and reduce the chance of problems and injuries. Develop categories to identify problem areas. Track and trend all patient grievances and complaints. Perform an analysis of all patient complaints that relate to patient care and medical services. Establish steps and time tables to investigate grievances, communicate findings to patients and staff, develop action plans, and evaluate effectiveness of changes in processes or systems. To compare select performance measures, you may locate information on how others are performing on key performance measures through specialty groups, ASC groups, and national studies. Your Ambulatory Surgical Center Quality Reporting (ASCQR) report from the Quality Net website (www.qualitynet.org), which shows your performance compared to others, may pinpoint areas where your surgery center’s performance could improve. Risk management processes to reduce risk are similar to quality improvement processes to identify the problem, review alternatives or ways to overcome the problem, implement an action plan, and review to determine if the action plan worked. Risk management should be integrated into quality improvement activities. If there are any trends or patterns in