Event Reporting - Crozer-Keystone Health System - PA

Event Reporting - Who, What, When, Where and Why?  

Event Reports are not just a nursing document. Many believe that only nursing staff are responsible for completing an Event Report post an event or near miss, yet, it is everyone’s responsibility to ensure an Event Report is completed. Reports should be completed by anyone who discovers, witnesses or becomes aware of circumstances indicative of an unusual event involving a patient, visitor, or other. It is better to have more than one report on an event than no reports. The reports are reviewed by a variety of department administrators in an attempt to understand what took place, when, where, and why. Event Reports are designed to be an administrative tool to report events and near misses so that they can be reviewed and investigated on an individual basis as well as an aggregate basis.  

A Near Miss is defined as an event that would have constituted an error, but which was intercepted at the point of care before it reached the patient. An Event is defined as a scenario which is unusual, not consistent with routine operations, or one which required some intervention, increased monitoring, or follow up care to a patient regardless of injury or not.   

Reports are intended to protect patients, visitors, and staff from harm by identifying risk exposures so that action can be taken to prevent and/or reduce additional events and near misses. The reports serve as a first notice that a problem, real/potential, exists. Once a problem is identified then the appropriate evaluation and corrective action plan can be made. This might include: change in physical surroundings if event was a fall, change in how medication is stored if event was a medication error, review of policy if universal protocol not followed, change in communication process if patient identification issue. Some problems may be simple to resolve, but others may require a team approach for closure. A small number of events necessitate a Process Review Meeting. These meetings are multi-department in nature and are designed to assess the process as opposed to focus on the individuals involved with an event. Recommendations from these meetings are shared  internally across CKHS so that best practices can be developed. Lessons learned from one event can be valuable when following up with a different event. 

Reports serve to highlight those scenarios which may require an immediate response to remedy the problem/concern at hand. There are times when an intervention such as team meeting, bill write off, or service recovery action may be needed. The reports allow for notice and response by the appropriate parties to address the scenario to bring closure, if possible. 

Reports are also intended to serve as a notice to administration so that various external reports can be generated per various regulatory bodies. For example, the Patient Safety Authority, Department of Health, and the Safe Medical Device Act require mandatory reporting of given events with specific time tables. Additionally, reports may be made to the hospital’s insurance carrier to put them on notice of a potential compensable event. 

Reports are valuable in assessing the strengths and weakness of the organization by looking at the data on an aggregate level. For example, falls and medication errors are looked to determine if there are any patterns or trends over a given period in time. This helps to evaluate where the problems may be and if corrective action taken has helped to resolve the problem or not.

An Event Report is a legal document so it is important to ensure that what is documented is an accurate account of what the author knows to be true. The report should be objective in nature without opinions or speculation. Important things to capture include: patient name, DOB, date/time the event took place, brief statement of what happened, who witnessed the event, and who was notified of the event. The form provides for prompts to better assess and memorialize information about the event.  There are specific prompts broken down in four categories: Falls, Medication errors/IV/Transfusion Related, Equipment/Device, and Other. It is important to capture as much information as possible so a full understanding of what happened can be made or further investigated. 

For those events involving a medical device the given piece of equipment should be secured for evaluation, per hospital policy. Clinical Engineering should be contacted, as appropriate, or the product saved for Risk Management to review and follow up.  All “evidence” needs to be secured and be forwarded with the Event Report. 

Event Reports should be completed, submitted to the respective supervisor for the department and then forwarded to Risk Management or Quality within 24 hours.  For those scenarios involving an injury or death a phone call should be made asap with the Event Report to follow. Event Reports are NOT punitive; however, they may be submitted anonymously if someone is uncomfortable completing one. The important thing is to complete and forward to the appropriate parties. If there are questions regarding completion or intent of an Event Report, contact Risk Management at 610-447-2764 of 610-284-8156.  

Event Reporting - Who, What, When, Where and Why?  Questions/Answers

Event Reporting - Who, What, When, Where and Why? March 2011 Questions and Answers

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