how do you categorize quality events?

[Mabel Adams]

My system is a work in progress that I created in Excel. Once I get it perfected, I want to move it to Access so it maybe isn't so clunky (if I ever get time). It doesn't work very well in Excel to have sub-categories to an incident--at least how I know how to use Excel. Taking any and all advice on how to do that.

I will try to share what I have when I can get to it more easily.

[Mabel Adams]

Here is a template of my homebrew system. I narrowed the columns so it is easier to see the stuff to the right. I usually free text the situation into the cells and they sometimes get too big and unwieldy, but I like the concepts. EMS= our hospital-wide event mgt system which is good for issues between depts and big things admin should know about, but not much good to me for tracking internal problems. Always looking for ways to improve.[ATTACH]611[/ATTACH]

[mm_ribc]

We consider each event an occurrence. In our error management process we need to identify where the process is failing and if someone at an upper level is not reviewing multiple steps, we have a way to at least flag that there is a problem and determine if it is related to a specific employee. This isn't punitive, it is a process improvement action. Employees are counseled individually and the types of errors/events occurring are classified.

[Liz]

What if an employee is counseled once and repeats the mistake.

[JoyDenver]

If you have a series of mistakes do you record each mistake in the process separately or do you treat them all as one event. Let's say someone omits entering a BB armband # in the BBIS. Someone else crossmatches the units for a remote site. Someone at the remote site tags the units. Then someone else issues them. No one catches the missing band number. Is this tracked as one error or 4? My error tracking system includes an estimate of how likely the problem is to recur and I find that I would give different estimates for different mistakes in the event. I find the likelihood measure useful in assessing risk but I don't really want to look at only how often all of the mistakes would line up together again. I use a homemade system so I can change it all I want.

The first two occurrences happened at your facility the other 2 at the remote location. So your QA incident accessment should only track those errors