Reporting Adverse Events and Concerns at Stroger Hospital
Case Pt on coumadin comes in for community acquired pneumonia and is started on levaquin After several days, you note a lot of bruising.. You realize you don t have an INR since admission, so you order one and it comes back 7.1
What Do You Do? First things first: Is there an injury or potential for injury? take the immediate action necessary for safety and patient care. THEN REPORT IT! There are different ways to report different kinds of problems and events.
How to Report Definitions You Need to Know: Incident: An incident is any event which is not consistent with usual operations and may result in an injury, perceived injury or risk of injury to a patient or visitor, or staff member. This includes, for example, patient, visitor or employee falls and injuries; altercations; patients absconding, equipment failures, etc. Adverse Drug Reaction: When the correct medication, administered correctly, causes an unexpected, unintended, or undesired detrimental effect. Adverse drug reactions are reported to the FDA by Pharmacy using the Med Watch system.
How to Report Definitions You Need to Know: Medication Error: A preventable incident that causes, or may cause, or lead to inappropriate medication use or harm to the patient. This includes close calls, in which an error is caught before it reaches the patient, and unsafe situations that could lead to a medication error as well as those errors that do reach the patient. Errors can be errors in prescribing, dispensing, administering, documenting or monitoring.
How to Report Definitions You Need to Know Never Events- Hospital Acquired Conditions There are different definitions and lists from Medicare & Medicaid (CMS); Illinois Law and the National Quality Forum (NQF) and different reporting requirements from different agencies, but a basic definition is: Clearly identifiable, serious, largely preventable errors or preventable conditions of consequence to the patient, public and healthcare providers. Some examples: (not the complete list). Surgical Errors: Wrong site or wrong patient ; unintentional retention of foreign objects; unexpected death of a normal, healthy patient during or right after surgery. Some surgical infections. Certain hospital-acquired infections. Hospital-acquired serious pressure ulcers Death or serious injury related to contaminated drugs, misuse of devices, restraints, air embolism, DVT embolism, patient elopement, med errors, diabetes control, inpatient suicide attempt.
How to Report Never Events- Medicare/Medicaid and insurance companies will not reimburse hospitals for the cost of caring for patients with conditions caused by a never event and patients must not be billed. WHAT TO DO: MANDATORY REPORTING Report any never event immediately to your supervisor. Supervisors must report it up the chain of command. If a serious injury occurred then Quality Assurance must be notified immediately. During regular office hours: 4-0800 After regular office hours: 312-839-6117 (pager)
How to Report Definitions You Need to Know: Sentinel Events: An unexpected occurrence that results in an unanticipated death, or serious injury or major permanent loss of function, not related to the natural course of the patient s illness or underlying condition. Includes all never events SENTINEL EVENTS (even if no actual injury to the patient occurs): Suicide in the hospital or within 72 hours of discharge. Unanticipated death of a full-term infant. Abduction of any patient receiving care, treatment and services. Discharge of an infant to the wrong family. Rape (unconsented sexual contact) Hemolytic transfusion reaction involving major blood or blood product incompatibilities. Surgery on the wrong patient or wrong site surgery. Unintended retention of a foreign object in a patient after surgery/procedure. Severe neonatal hyperbilirubinemia (> 30 milligrams/deciliter) Prolonged fluoroscopy with a cumulative dose >1500 rads to a single field or any radiotherapy to the wrong body region or greater than 25% of the planned dose.
How to Report Sentinel Events: Report any sentinel event to your supervisor immediately Supervisors must immediately report it up the chain of command. Quality Assurance must also be notified immediately. During regular office hours: 4-0800 After regular office hours: 312-839-6117 (pager)
Don t Forget! Any equipment, IV tubing, etc. involved in a mishap must be sequestered. IV pumps and monitors suspected of being part of an adverse event must be taken out of service and all settings must be left as they were not cleared, not reset. Equipment goes to Clinical Engineering. 864-2550 IV tubing, medication vials, IV bags, etc. must be bagged and saved for Risk Management. Ask the Charge Nurse or Nurse Coordinator for assistance.
Back to Our Case Pt on coumadin was started on Levaquin and her INR was not monitored. How do you classify the incident?
Reporting Incidents You decide that the correct medicine was rx d, but you failed to monitor the INR even though there is a known interaction between coumadin and Levaquin. You decide that this is a Medication Error. The patient at this time is fine. How do you report it?
Reporting an INCIDENT, MEDICATION ERROR, or ADVERSE DRUG REACTION: Medical Event Reporting System (MERS) Go to the home page and scroll to the very bottom
Click Here Medical Error Reporting = MERS This allows you to file a report on-line!
When You Click on Event You will be prompted for your System Log In and Password:
Note that you have the option of completing this anonymously-
Fill In the Form (Note the Save and Continue is at the top of the page) When you are finished, submit it directly to Risk Management TIP: If You enter the Medical Record Number, all of the pt s information will populate the form
Review Report Through MERS: Adverse Events Includes Medication Error, Adverse Drug Reactions Incidents such as Pt Falls, Visitor Falls, Patient Absconding Report Immediately to your Supervisor Never Events Sentinel Events When in Doubt, Call Quality Assurance at 4-0800
Reporting Other Concerns Internal Disasters (for example, fire, hazardous spills, Code Pink) 4-8888 Hospital Police 4-8097 Patient Complaints (Patient Relations Dept.) 4-0185 Any patient safety concern 4-0804 or 4-0800 Any safety environment of care concern 4-0440 or 312-839- 3744 Any risk management concern 4-0821 or 312-203-4505 Any employee, patient or family member has the right to report concerns to regulatory agencies The Joint Commission- Oak Brook Illinois 630-792-5636 IDPH 800-782-7860