An incident or OVR (Occurrence Variances Report) is defined as a written or verbal reporting of any event in the process of patient care that is inconsistent with the deserved patient outcome or routine operations(policies and Procedures) of BCMCH.
Incident reporting/ OVR is a crucial aspect of patient safety and quality improvement in BCMCH. It involves the systematic documentation and analysis of events that have the potential to cause harm or have already caused harm to patients, staff, or visitors.
The goal of incident reporting is to:
Identify and understand the root causes (RCA, Root Cause Analysis) of incidents.
Calculate the risk of the events (Risk Analysis)
Implement Risk Mitigation / corrective and preventive actions to prevent similar incidents from occurring in the future.
Create a culture of safety and learning within BCMCH.
Incidents can include a wide range of events, such as:
Medication errors
Patient falls
Surgical site infections
Equipment malfunctions
Near misses (events that could have resulted in harm but did not)
Adverse events
Sentinel events
(refer to the categories and sub categories of BCMCH Incident Reporting)
Patient Safety: Incident reporting allows healthcare organizations to proactively identify and address potential safety hazards before they cause harm.
Calculation of Risk and Proactive Quality improvements: Incident reporting is required for the correct identification of Frequency or likelyhood of events, which is used for risk calculation
Quality Improvement: By analyzing incident data, healthcare organizations can identify trends and patterns that can inform quality improvement initiatives.
Learning and Development: Incident reporting provides valuable opportunities for healthcare professionals to learn from mistakes and improve their practice.
Accountability and Transparency: Incident reporting promotes accountability and transparency within the healthcare organization.
The NABH Accreditation Standards for Hospitals emphasize the importance of incident reporting and require healthcare organizations to have a robust incident management system in place.
Key requirements of NABH standards include:
Establishment of an incident management system: This system should define the process for reporting, investigating, and analyzing incidents.
Identification of sentinel events: Sentinel events are defined as unexpected occurrences involving death or serious physical or psychological injury, or the risk thereof. Organizations must have a mechanism to identify and investigate sentinel events.
Analysis of incidents: All incidents should be investigated to determine the root causes.
Implementation of corrective and preventive actions: Based on the findings of the incident analysis, corrective and preventive actions should be taken to prevent similar incidents from recurring.
Incorporation of risks into the risk management system: Risks identified through incident analysis should be incorporated into the organization's overall risk management system.
The process for reporting an incident is detailed inthe OVR Software.
Generally, the following steps are involved:
Complete an incident report form: This form should capture all relevant details about the incident, including the date, time, location, people involved, and a description of what happened.
Submit the incident report to the appropriate person or department: This may be the risk manager, quality improvement department, or a designated incident reporting hotline.
Participate in the investigation process: If necessary, you may be asked to provide additional information or participate in an interview as part of the investigation.
Incident reporting is an essential element of patient safety and quality improvement in healthcare. By encouraging a culture of reporting, healthcare organizations can learn from mistakes, prevent future harm, and continuously improve the quality of care they provide.