Event Management!

[tcoyle]

In our institution we are discussing what occurrences should be sent through our entire event management process. We are doing some benchmarking to see how other institutions are processing these items. We have three questions:

1. What system or categorizations or definitions do you have to define an event from a “non-event”?

2. What criteria are used to qualify an occurrence to become a recorded event (sent through event management process, but not necessarily reported to FDA) in your institution?

3. Do you have a "threshold" defined for those occurrences that are not considered an event but would be considered an annoyance that needs to be looked at?

Thanks in advance for your responses!

[tbostock]

Events that we enter in our occurrence management system include mislabeled BB specimens, blood order problems (wrong patient or wrong blood product), blood wastage, testing errors, blood admin errors (going past 4 hours, not following transfusion reaction protocol, etc).

The definition of an event is that it caused the patient harm or had the potential for harm. We are not allowed to enter problems with rude nurses, difficult doctors, or anything that would not have impacted patient care.

My techs fill out all incidences on a paper variance form, which I review. I decide whether it qualifies for event reporting in the hospital system, or if it needs to be reviewed by my Medical Director, or reported to the Dept of Health or the FDA.

[Malcolm Needs ☆]

We are not allowed to enter problems with rude nurses, difficult doctors, or anything that would not have impacted patient care.

Just as a matter of interest Terri, when, for example, a "difficult doctor" tries to insist that you use an unlabelled or poorly labelled sample, that he or she is "willing" to "relabel", is that reportable as an event; because I think that it should be.

[SMILLER]

Our system here is very simular to Terri's. In the US, the FDA is pretty definite about what is and what isn't reportable to them.

(Not as familiar with the JCAHO regs on event reporting in general, but if somehow a doc actually got away with Malcolm's example, we would write it up).

Scott

[PAWHITTECAR]

As most of you know I just took over as supervisor here and in reviewing the procedures found that they had been allowing physicians to sign a release to have a mislabeled blood bank specimen tested. Needless to say that was the first thing to go. I have butted heads with several physicians since then and even had a call from the CEO whom I explained that this was not negotiable. The risk was just too great. I think that any physician of nurse insisting a mislabeled specimen be tested should be considered on occurance.

[tbostock]

Just as a matter of interest Terri, when, for example, a "difficult doctor" tries to insist that you use an unlabelled or poorly labelled sample, that he or she is "willing" to "relabel", is that reportable as an event; because I think that it should be.

As far as our hospital policy is concerned, that would not be an occurrence because we would always follow our policies by not ever accepting mislabeled or unlabeled tubes. However, if the physician refused to have the blood redrawn, we would give uncrossmatched blood, and then it would be an occurrence because he/she put the patient at a higher risk. So we look at each case and decide. If we wrote up each doctor or nurse that asked us to break a policy, I would get writer's cramp. :tongue:

[Dr. Pepper]

Our system is very similar to Terri and Scott's. As with Terri, we have an internal QA form that is filled out for every incident, big or small. Many years ago I made a QA database in Access. The internal form is a quick checkoff list to document the problem and action taken and serves as an entry form for the database. The lab section supervisor then reviews it and, like Terri, will decide if it needs to go up the ladder. (This is a key step in the process, ensuring that all incidents have been properly acted upon and that appropriate ones are forwarded.) The Access database greatly facilitates review and quantification of the extent of any problem and is used to track many of the lab's QA monitors.