Accurately categorizing incidents is a critical step in the Occurrence Variance Report (OVR) process at BCMCH. Proper categorization ensures that reported events are classified consistently, allowing for effective data analysis, trend identification, and targeted quality improvement efforts. This module will detail the various incident types used within the BCMCH OVR system, based on the provided list, to equip you with the knowledge to correctly categorize incidents you encounter or report.
The following categories represent the types of incidents that are tracked and reported through the OVR system at BCMCH. Understanding each category is essential for accurate reporting and effective analysis of safety events.Â
Description: This category encompasses incidents related to the availability, maintenance, security, and appropriate utilization of hospital assets and resources. This includes physical assets, equipment, supplies, and infrastructure.
Examples of Incidents:Â
Equipment Malfunction: Failure of critical medical equipment (e.g., ventilator malfunction, IV pump failure, diagnostic imaging equipment breakdown) impacting patient care or operations.
Supply Shortages: Lack of essential medical supplies (e.g., medications, IV fluids, personal protective equipment (PPE), surgical instruments) leading to delays in care or potential compromises in safety.
Security Breaches: Theft or loss of hospital property, unauthorized access to restricted areas or sensitive information, security system failures.
Utility Failures: Loss of power, water, gas, or HVAC systems impacting patient care areas or essential services.
Facility Issues: Structural problems, leaks, or environmental hazards within the facility that could pose a risk to patients, staff, or visitors.
Why Report: Incidents in this category can disrupt patient care, compromise safety, lead to financial losses, and impact operational efficiency. Reporting helps identify systemic issues in resource management, maintenance, and security.
Description: This category focuses on incidents related to the provision of safe, appropriate, and timely dietary and nutritional services to patients.
Examples of Incidents:
Dietary Errors: Serving the wrong diet to a patient (e.g., regular diet to a patient ordered NPO, incorrect texture modification), leading to potential aspiration risk or dietary management issues.
Food Safety Issues: Suspected food poisoning, contamination of food, improper food handling or storage practices.
Meal Delays: Significant delays in meal delivery impacting patient care, especially for patients with specific dietary needs or medication schedules tied to meals.
Nutritional Support Errors: Errors in the preparation or administration of enteral or parenteral nutrition, leading to metabolic imbalances or complications.
Allergic Reactions due to Dietary Services: Allergic reactions in patients due to improperly labeled food or cross-contamination in food preparation.
Why Report: Dietary and nutritional services are crucial for patient recovery and well-being. Errors in this area can lead to adverse health outcomes, allergic reactions, and dissatisfaction. Reporting helps improve the safety and quality of nutritional care.
Description: This category encompasses incidents related to patient falls and injuries sustained within the hospital environment. It also includes near misses related to falls.
Examples of Incidents:
Patient Falls: Any instance where a patient unintentionally comes to rest on the ground or a lower surface (e.g., falls from bed, chair, while ambulating, in the bathroom).
Injuries from Falls: Fractures, head injuries, lacerations, or other injuries sustained as a result of a fall.
Near Falls: Situations where a patient almost fell but was caught or recovered balance before falling to the ground. These are important to report as they indicate potential fall risks.
Environmental Hazards Contributing to Falls: Wet floors, cluttered pathways, inadequate lighting, malfunctioning equipment (e.g., bed alarms), improper use of restraints.
Why Report: Falls are a significant cause of morbidity and mortality in hospitals. Reporting falls and near falls helps identify risk factors, environmental hazards, and process weaknesses in fall prevention programs, enabling targeted interventions to reduce patient falls and injuries.
Description: This category includes incidents occurring during surgical procedures that are not directly related to anesthesia (which has its own category). It focuses on procedural errors and unintended events within the operating room.
Examples of Incidents:
Wrong Site Surgery: Performing surgery on the incorrect body part or side of the patient.
Wrong Patient Surgery: Performing surgery on the wrong patient due to misidentification.
Retained Surgical Items: Leaving surgical instruments, sponges, or other materials inside the patient's body after surgery.
Surgical Errors: Unintended damage to organs or tissues during surgery, procedural errors leading to complications.
Equipment Malfunction during Surgery: Failure of surgical equipment during a procedure (e.g., surgical robot malfunction, cautery device failure).
Why Report: Intra-operative mishaps can have severe and potentially life-threatening consequences for patients. Reporting these events is crucial for identifying system failures in surgical safety protocols, team communication, and procedural adherence, enabling improvements to prevent such critical errors.
Description: This category specifically addresses adverse events related to anesthesia administration during surgical or other procedures.
Examples of Incidents:
Adverse Drug Reactions to Anesthesia: Unexpected and harmful reactions to anesthetic agents.
Respiratory Events during Anesthesia: Difficult intubation, airway obstruction, aspiration, hypoxia, or other respiratory complications during anesthesia.
Cardiovascular Events during Anesthesia: Hypotension, hypertension, arrhythmia, cardiac arrest related to anesthesia.
Awareness under Anesthesia: Patient experiencing consciousness or recall during a procedure intended to be performed under general anesthesia.
Equipment Malfunction related to Anesthesia Delivery: Failure of anesthesia machines, monitoring equipment, or airway devices.
Why Report: Anesthesia-related events can have serious and immediate consequences for patients. Reporting these incidents allows for analysis of anesthesia protocols, equipment reliability, and staff training in anesthesia management, leading to safer anesthetic practices.
Description: This category encompasses incidents associated with intravenous (IV) access and therapy, including complications related to IV insertion, maintenance, and medication/fluid administration.
Examples of Incidents:
IV Infiltration or Extravasation: IV fluid leaking outside the vein into surrounding tissues, potentially causing pain, swelling, tissue damage, or medication extravasation injuries.
Phlebitis: Inflammation of a vein, often caused by IV catheter insertion, leading to pain, redness, and swelling.
IV Line Infections: Local site infections or bloodstream infections (BSI) related to IV catheters.
Air Embolism related to IV Therapy: Air entering the venous system through an IV line.
IV Medication Errors: Errors specifically related to IV medication administration (e.g., wrong rate, wrong drug via IV route, incompatibility issues).
IV Catheter Occlusion or Displacement: Blockage or accidental removal of an IV catheter.
Why Report: IV therapy is a common and essential aspect of patient care, but it carries inherent risks. Reporting IV-related complications helps identify best practices for IV insertion, maintenance, medication administration, and staff training to minimize these complications and improve patient comfort and safety.
Description: This category includes incidents related to laboratory testing and blood collection (phlebotomy) processes. This covers the entire testing cycle from order to result reporting.
Examples of Incidents:
Wrong Blood in Tube (WBIT): Collecting blood samples from the wrong patient, leading to potentially incorrect test results and misdiagnosis.
Specimen Labeling Errors: Incorrectly labeling specimen tubes, leading to misidentification and potential patient harm.
Specimen Collection Errors: Improper specimen collection technique, wrong collection tube, insufficient sample volume, leading to inaccurate test results or need for repeat collection.
Testing Errors: Errors in laboratory testing procedures, equipment malfunction, reagent issues, leading to inaccurate or unreliable results.
Result Reporting Errors: Reporting results to the wrong patient record, delayed reporting of critical results, transcription errors in reporting.
Phlebotomy-Related Injuries: Needle stick injuries to phlebotomists or patients, excessive bleeding or hematoma formation after blood draw.
Why Report: Accurate and timely laboratory results are essential for diagnosis, treatment, and monitoring patient conditions. Errors in the lab process can have serious consequences. Reporting these incidents helps improve laboratory processes, phlebotomy techniques, quality control, and overall diagnostic accuracy.
Description: This category focuses on incidents related to patient medical records and clinical documentation, including accuracy, completeness, accessibility, and confidentiality.
Examples of Incidents:
Documentation Errors: Inaccurate, incomplete, or illegible documentation in patient medical records.
Missing Documentation: Essential parts of the medical record are missing (e.g., progress notes, consent forms, test results).
Wrong Chart Documentation: Documenting information in the wrong patient's medical record.
Confidentiality Breaches: Unauthorized access to or disclosure of patient medical information, violations of privacy regulations.
Loss or Damage of Medical Records: Physical loss, damage, or destruction of paper records or electronic data loss.
Delays in Accessing Medical Records: Difficulty or delays in retrieving patient medical records when needed for patient care.
Why Report: Accurate and complete medical records are vital for effective communication, continuity of care, legal documentation, and quality review. Errors in medical records can lead to miscommunication, treatment errors, compromised confidentiality, and legal risks. Reporting these incidents helps improve documentation practices, record management systems, and data security.
Description: This is a broad category covering incidents related to all aspects of the medication use process, from ordering and prescribing to dispensing, administration, and monitoring.
Examples of Incidents:
Medication Errors (General): Any preventable event that may cause or lead to inappropriate medication use or patient harm. This is a broad umbrella covering various types of medication errors.
Wrong Drug Errors: Administering or dispensing the wrong medication.
Wrong Dose Errors: Administering or dispensing an incorrect dose (too high or too low).
Wrong Route Errors: Administering medication via an incorrect route of administration.
Wrong Time Errors: Administering medication at the wrong time or frequency.
Omission Errors: Failing to administer a prescribed medication.
Unauthorized Drug Errors: Administering a medication that was not prescribed.
Drug-Drug Interactions: Adverse effects due to interactions between multiple medications.
Adverse Drug Reactions (ADRs): Harmful and unintended responses to a medication at normal doses.
Allergic Reactions to Medications: Allergic responses to medications.
Prescribing Errors: Incorrect medication selection, dosage, route, or frequency in the prescription order.
Dispensing Errors: Errors made in the pharmacy during medication dispensing.
Administration Errors: Errors made by nurses or other staff during medication administration.
Monitoring Errors: Failure to adequately monitor patients for therapeutic effects or adverse effects of medications.
Why Report: Medication errors are among the most common types of preventable errors in healthcare and can have serious consequences. Reporting medication safety incidents across the entire medication use process is critical for identifying system weaknesses, improving medication safety protocols, implementing error prevention strategies, and ultimately reducing medication-related harm to patients.
Description: This category specifically addresses injuries caused by needles or other sharps that penetrate the skin, potentially exposing healthcare workers or others to bloodborne pathogens.
Examples of Incidents:
Needle Stick Injuries: Accidental puncture wounds from needles used for injections, blood draws, or other procedures.
Sharps Injuries: Cuts or punctures from other sharp objects like scalpel blades, suture needles, broken glass vials, or contaminated sharps containers.
Exposure to Blood or Body Fluids: Contact with blood or other potentially infectious materials through sharps injuries.
Contamination of Sharps Containers: Overfilling or improper handling of sharps disposal containers.
Why Report: Needle stick and sharps injuries pose a significant risk of exposure to bloodborne pathogens like Hepatitis B, Hepatitis C, and HIV for healthcare workers and others. Reporting these injuries is essential for providing appropriate post-exposure prophylaxis, tracking injury trends, identifying high-risk procedures or areas, and implementing safer sharps handling practices and engineering controls to prevent future injuries.
Description: This is a catch-all category for incidents that do not fit neatly into any of the other predefined categories. It should be used judiciously and with a clear description of the incident.
Examples of Incidents:
Visitor Injuries: Injuries sustained by visitors within the hospital premises that are not directly related to patient care (e.g., slips and falls not related to patient areas, injuries from facility issues).
Security Incidents not classified under Asset Management: Patient elopement, violent incidents, or other security concerns not directly involving asset loss.
Ethical Concerns: Situations raising ethical dilemmas or potential breaches of patient rights that are not covered by other categories.
Communication Breakdowns not directly related to Patient Care (IPSG 2): Significant communication failures within departments or between departments that don't directly involve patient information exchange, but impact operations or safety.
Why Report: While "Others" is a broad category, it's important to have a mechanism to capture incidents that are important to report and learn from, even if they don't perfectly align with the other defined categories. When using "Others," provide a detailed and specific description in the OVR report to ensure clarity and proper analysis.
Description: This category focuses specifically on incidents related to patient misidentification or failures in patient identification processes, aligning with IPSG 1.
Examples of Incidents:
Misidentification Errors: Any situation where a patient is misidentified, or there is a risk of misidentification, during any aspect of care.
Failure to Verify Patient Identity: Not properly checking patient identifiers before procedures, medication administration, blood transfusion, or specimen collection.
Using Single Identifiers: Relying on only one patient identifier (e.g., room number) instead of using at least two validated identifiers.
Identification Band Issues: Missing, incorrect, or illegible patient identification bands.
Patient Mix-ups: Accidental swaps or confusion between patients, leading to potential errors.
Why Report: Patient misidentification is a fundamental safety risk that can lead to a wide range of serious errors. Reporting these incidents, including near misses, is crucial for reinforcing patient identification protocols, improving staff adherence to these protocols, and preventing wrong-patient errors.
Description: This category encompasses incidents related to violations of patient rights, patient dissatisfaction related to quality of care or service, and ethical concerns.
Examples of Incidents:
Breaches of Confidentiality: Unauthorized disclosure of patient information, violations of privacy rights.
Lack of Informed Consent: Procedures or treatments performed without proper informed consent from the patient.
Denial of Patient Rights: Violation of patient rights related to access to care, respect, dignity, or other legally recognized rights.
Patient Complaints related to Quality of Care: Formal complaints from patients or families expressing dissatisfaction with aspects of care, communication, or service delivery.
Ethical Dilemmas or Concerns: Situations raising ethical questions or potential ethical breaches related to patient care decisions, end-of-life care, or resource allocation.
Discrimination or Bias in Care: Concerns about unequal or biased treatment of patients based on race, ethnicity, gender, religion, or other protected characteristics.
Why Report: Respecting patient rights and ensuring patient satisfaction are essential components of quality healthcare. Reporting incidents in this category helps identify areas where patient rights may be compromised, service delivery can be improved, and ethical concerns need to be addressed, fostering a patient-centered and ethical care environment.
Description: This category specifically addresses incidents related to the development and management of pressure ulcers (bedsores) in patients.
Examples of Incidents:
Development of New Pressure Ulcers: Patients developing new pressure ulcers during their hospital stay (categorized by stage/severity).
Worsening of Existing Pressure Ulcers: Existing pressure ulcers progressing to a more severe stage during hospitalization.
Inadequate Pressure Ulcer Prevention: Failure to implement or consistently apply pressure ulcer prevention strategies for at-risk patients (e.g., repositioning schedules, pressure-relieving devices, skin assessments).
Inadequate Pressure Ulcer Treatment: Delays or errors in the appropriate treatment of existing pressure ulcers.
Why Report: Pressure ulcers are a common hospital-acquired condition that can cause significant pain, infection, and prolonged healing time, impacting patient quality of life and length of stay. Reporting pressure ulcer incidents helps monitor prevalence rates, identify risk factors, evaluate the effectiveness of prevention protocols, and improve pressure ulcer management practices.
Description: This category is for incidents where established policies, procedures, or protocols were not followed, potentially leading to an adverse event or near miss. This is a broad category and requires specifying which procedure was not followed.
Examples of Incidents:
Deviation from Standard Operating Procedures (SOPs): Staff not adhering to established SOPs for specific tasks or processes (e.g., medication preparation, equipment sterilization, patient transfer procedures).
Bypassing Checklists or Safety Protocols: Omitting steps in checklists, safety protocols, or verification processes designed to prevent errors.
Failure to Follow Policy: Violations of organizational policies related to patient care, safety, or administrative processes.
Non-compliance with Guidelines: Not adhering to established clinical guidelines or best practices.
"Workarounds" or Unapproved Practices: Staff developing or using unapproved shortcuts or alternative methods that deviate from established procedures.
Why Report: Failure to follow established procedures is a common root cause of many types of errors. Reporting "Procedure Not Followed" incidents helps identify areas where procedures are unclear, impractical, poorly communicated, or where staff compliance is low. This allows for review and improvement of procedures, enhanced training, and strategies to improve adherence. Crucially, when reporting "Procedure Not Followed," you must clearly specify which procedure was not followed in the OVR description.
Description: This category pertains to incidents related to the collection, reporting, or achievement of quality measures and performance indicators. This is often relevant for hospital accreditation and public reporting requirements.
Examples of Incidents:
Data Collection Errors for Quality Measures: Inaccurate or incomplete data collection for key quality indicators (e.g., infection rates, readmission rates, patient satisfaction scores).
Reporting Errors for Quality Measures: Errors in data entry, analysis, or reporting of quality measure data to internal or external stakeholders (e.g., regulatory bodies, accreditation organizations).
Failure to Meet Quality Measure Targets: Not achieving established targets or benchmarks for key quality indicators.
Missed Opportunities to Collect Quality Measure Data: Failure to collect necessary data points during patient care that are required for quality measure calculation.
Why Report: Accurate and reliable quality measure data is essential for monitoring performance, identifying areas for improvement, demonstrating accountability, and meeting external reporting requirements. Reporting incidents related to quality measures helps ensure data integrity and drives efforts to improve performance on key quality indicators.
Description: This category focuses on incidents related to communication breakdowns or failures in reporting critical information that are not directly covered under IPSG 2 (which is more about direct patient care communication). This category is broader and can include internal organizational communication issues.
Examples of Incidents:
Delayed Reporting of Critical Information: Delays in reporting important patient information, equipment malfunctions, or safety concerns to appropriate personnel.
Miscommunication within Departments or Teams: Communication breakdowns leading to errors or delays in operations that are not direct patient care communication failures (which would be IPSG 2).
Failure to Escalate Concerns: Staff failing to escalate safety concerns or critical issues through the appropriate channels.
Ineffective Communication Tools or Systems: Problems with communication systems (e.g., pager failures, phone system issues) hindering timely communication.
Lack of Feedback on Reported Issues: Failure to provide feedback to staff who report incidents or concerns, potentially discouraging future reporting.
Why Report: Effective communication and timely reporting are vital for a safe and efficient healthcare environment. Failures in these processes can lead to delays in care, unresolved safety issues, and a breakdown in teamwork. Reporting these incidents helps identify communication gaps, improve reporting pathways, and foster a culture of open communication and feedback.
Description: This category specifically addresses incidents related to non-compliance with standard precautions designed to prevent the transmission of infections, such as hand hygiene and PPE use.
Examples of Incidents:
Hand Hygiene Non-compliance: Observed instances of healthcare workers not performing hand hygiene at appropriate times (e.g., before and after patient contact, after removing gloves).
Inadequate Use of Personal Protective Equipment (PPE): Failure to wear appropriate PPE (gloves, masks, gowns, eye protection) when indicated based on risk of exposure to blood or body fluids.
Improper PPE Donning or Doffing: Incorrect techniques for putting on or taking off PPE, potentially leading to contamination.
Lack of Availability of Hand Hygiene Supplies or PPE: Shortages or inaccessibility of hand sanitizer, soap, gloves, or other PPE in patient care areas.
Why Report: Consistent adherence to standard precautions is a cornerstone of infection prevention. Non-compliance increases the risk of healthcare-associated infections for both patients and staff. Reporting these incidents, even observed non-compliance without immediate harm, helps monitor compliance rates, identify barriers to adherence, and reinforce the importance of standard precautions through education and process improvements.
Description: This category focuses specifically on incidents related to blood transfusion processes, aiming to prevent transfusion-related errors and adverse reactions.
Examples of Incidents:
Wrong Blood Transfusion (WBOT): Transfusing blood components to the wrong patient due to misidentification or errors in the transfusion process.
Transfusion Reactions: Adverse reactions to blood transfusions (e.g., febrile non-hemolytic transfusion reactions, allergic reactions, transfusion-related acute lung injury (TRALI), hemolytic transfusion reactions).
Transfusion Administration Errors: Errors in blood product administration (e.g., wrong rate, wrong component, incorrect compatibility testing).
Blood Product Storage or Handling Errors: Improper storage temperatures, expiration of blood products, errors in blood product transport.
Documentation Errors in Transfusion Records: Inaccurate or incomplete documentation of transfusion procedures, patient monitoring, or reaction management.
Why Report: Blood transfusions are a potentially life-saving therapy, but they also carry significant risks of serious adverse reactions and errors. Reporting transfusion safety incidents is critical for improving transfusion processes, ensuring patient safety during transfusions, minimizing the risk of wrong blood in tube errors, and effectively managing transfusion reactions.