Commonwealth of Pennsylvania Department of Public Welfare Office of Mental Health & Substance Abuse Services Division of Quality Management

Transcription

1 Commonwealth of Pennsylvania Department of Public Welfare Office of Mental Health & Substance Abuse Services Division of Quality Management Community Risk Management: Incident Management: Summary Report for Calendar Year 2008

2 CONSUMERS Cleared Consumers Clearing a consumer within HCSIS involves the community mental health provider, the County Mental Health Program and/or OMHSAS headquarters performing data entry functions to register the consumer s demographic information (and where applicable, CHIPP participant information) into HCSIS to create a consumer record. While it is not necessary to first clear a consumer in order to report an incident on a consumer, by clearing the consumer first the process of reporting the incident is facilitated by the presentation of accurate, pre-populated consumer data. Figure 1. 4,000 OMHSAS HCSIS Incident Management: Cumulative Number of Consumers Cleared since Program Implementation 3,416 3,000 2,595 2,000 1,698 1,066 1, /01/06 06/18/07 12/04/07 7/7/ /24/08 1

3 INCIDENTS Categories When reporting an OMHSAS-reportable incident within HCSIS, the person is required to select from one of 12 predetermined categories. The categories were developed to provide structure and common definition to the classification of an incident. The following tables offer a summary of the categories of incidents reported during 2008: Total by T able 1. Calendar Year 2008, by Reported Incident in 2008 Abuse - Individual to Individual 128 Abuse - Staff to Individual 50 Death 28 Fire 22 Illness 979 Injury 211 Law Enforcement Activity 312 Missing Person 147 Neglect 10 Restrictive Procedures 56 Significant Medication Error 60 Suicide Attempt 58 TOTAL: 2,061 by Reporting Entity Of the 2,061 total incidents reported in 2008, the following chart and tables illustrate the breakdown, by reporting entity: 2

4 Figure 2 OMHSAS HCSIS Incident Management: Percent of Reported by Reporting Entity, for Calendar Year 2008 Long Term Structured Residences 17.76% County Mental Health Programs 6.94% Community Residential Rehabilitation Services 75.30% Table 2. Calendar Year 2008, by : Community Residential Rehabilitation Services CRRS Only CRRS Pct of Total, by Total Abuse - Individual to Individual % Abuse - Staff to Individual % Death % Fire % Illness % Injury % Law Enforcement Activity % Missing Person % Neglect % Restrictive Procedures % Significant Medication Error % Suicide Attempt % TOTALS: 1,552 2, % 3

5 Table 3. Calendar Year 2008, by : Long Term Structured Residences LTSR Only LTSR Pct of Total, by Total Abuse - Individual to Individual % Abuse - Staff to Individual % Death % Fire % Illness % Injury % Law Enforcement Activity % Missing Person % Neglect % Restrictive Procedures % Significant Medication Error % Suicide Attempt % TOTALS: 366 2, % T able 4. Calendar Year 2008, by : County Mental Health Programs County Only County Pct of, by Total Total Abuse - Individual to Individual % Abuse - Staff to Individual % Death % Fire % Illness % Injury % Law Enforcement Activity % Missing Person % Neglect % Restrictive Procedures % Significant Medication Error % Suicide Attempt % TOTALS: 143 2, % 4

6 Figure 3. OMHSAS HCSIS Incident Management: Top 5 Categories of Reported in Abuse - Individual to Individual 147 Missing Person 211 Injury 312 Law Enforcement Activity 979 Illness Table 5. Top Five Categories of Reported in Calendar Year 2008 Incident Number of Reported Percentage of Total Reported Illness % Law Enforcement Activity % Injury % Missing Person % Abuse - Individual to Individual % TOTALS: 1, % 5

7 Figure 4 OMHSAS HCSIS Incident Management: Top 5 Categories of Inidents Reported: Calendar year 2007 vs Abuse - Individual to Individual Missing Person Injury Law Enforcement Activity Illlness The analyses of the top 5 incident categories for 2007 and 2008 offer some interesting comparisons. Given the fact that the total number of incidents reported in calendar year 2008 (N=2,061) represented an approximately 10.8% increase over calendar year 2007 (N=1,860), the variation identified in the categories above necessitates further discussion. Subcategories Once the category has been selected, the incident reporter must then choose the one subcategory that best further classifies the incident. Each category has its own distict set of corresponding subcategories, as noted in the table on the following page: 6

8 Table 6. Calendar Year 2008, by Sub- Sub- Exploitation 5 Other 4 Abuse - Individual to Physical 83 Individual Psychological 17 Sexual 19 Exploitation 7 Other 10 Abuse - Staff to Individual Physical 19 Psychological 10 Sexual 4 Accident 1 Death Natural Causes 16 Other 9 Suicide 2 Fire with property damage 6 Fire Fire without property damage 14 Other 2 DOH reportable illness 5 Illness ER treatment/medical office 445 Hospital 506 Other 23 ER treatment/medical office 164 Injury Hospital 39 Other 8 Crisis intervention 119 Individual charged with a crime/under police investigation 64 Law Enforcement Activity Individual victim of crime 35 Other 92 Site crimes (vandalism, break-in, etc.) 2 Missing Person Immediate jeopardy 50 Missing more than 24 hours 97 Neglect Failure to provide needed care 9 Other 1 Restrictive Procedure Restraint with injury 1 Restraint without injury 55 ER Treatment/Medical Office 10 Significant Medication Error Hospital 4 Other 46 ER Treatment/Medical Office 12 Suicide Attempt Hospital 40 Other 6 TOTAL: 2,061 7