A brief lecture ppt for the students and professionals of Healthcare Quality Management & Patient Safety. This lecture presented in Arar Central Hospital of KSA for CME of doctors & nurses. Sentinel Events topic is a basic topic of Healthcare Quality Management and they can be controlled by caring of International Patient Safety Goals.

1. OVR
&
OVR
&
SENTINEL
SENTINEL
EVENTS
EVENTS
TQM
Department Lecture
By
Dr. Aqeel Ahmed Khan
QM
Coordinator-ACH

2. 2
CONTENTS:CONTENTS:
Definitions of termsDefinitions of terms
• OCCOURANCEOCCOURANCE
• OVROVR
• ADVERSE EVENTADVERSE EVENT
• VARIENCEVARIENCE
• NEAR MISS (& why it should beNEAR MISS (& why it should be
reported)reported)
• SENTINEL EVENTSSENTINEL EVENTS
• “ ““ “ (Types)(Types)
• “ ““ “ (policy)(policy)

3. 3
CONTENTS:CONTENTS:
• SENTINEL EVENTS (Procedure)SENTINEL EVENTS (Procedure)
• How to deal with sentinel/adverseHow to deal with sentinel/adverse
eventevent
• Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR
• Who should report /responsibilitiesWho should report /responsibilities
(Employee, attending physician, immediate(Employee, attending physician, immediate
supervisor, TQM department, safety officer)supervisor, TQM department, safety officer)
• OVR policyOVR policy
• OVR form restrictionsOVR form restrictions
• OVR form sampleOVR form sample

4. 4
OCCURRENCEOCCURRENCE
• An event which is not consistent with routineAn event which is not consistent with routine
patient care or with the routine operation ofpatient care or with the routine operation of
the facility & which adversely affects orthe facility & which adversely affects or
threatens the health or life of patient, visitor,threatens the health or life of patient, visitor,
employee, student or volunteer whichemployee, student or volunteer which
involves loss or damage to personal orinvolves loss or damage to personal or
hospital property. An occurrence alsohospital property. An occurrence also
includes any event that might other wiseincludes any event that might other wise
result in any other adverse situation or aresult in any other adverse situation or a
claim against the organization.claim against the organization.

5. 5
OCCURRENCEOCCURRENCE
VARIANCE REPORTVARIANCE REPORT
(OVR) DEFINITION:(OVR) DEFINITION:
• An internal form which is issued toAn internal form which is issued to
document the details of thedocument the details of the
occurrence / event and theoccurrence / event and the
investigation of an occurrence andinvestigation of an occurrence and
the corrective actions taken.the corrective actions taken.

6. 6
ADVERSE EVENTADVERSE EVENT
• It is an unwanted, undesirable andIt is an unwanted, undesirable and
usually unanticipated event such asusually unanticipated event such as
death of patient, an employee, or adeath of patient, an employee, or a
visitor in a health care organization.visitor in a health care organization.
Occurrences such as patient falls areOccurrences such as patient falls are
also considered adverse events ifalso considered adverse events if
there is no permanent effect on thethere is no permanent effect on the
patient.patient.

7. 7
VARIANCEVARIANCE
• Is the difference in results obtainedIs the difference in results obtained
in measuring the samein measuring the same
phenomenon more than once.phenomenon more than once.
Excessive variation frequently leadsExcessive variation frequently leads
to waste and loss; such as theto waste and loss; such as the
occurrence of undesirable patientoccurrence of undesirable patient
health outcomes and increased costhealth outcomes and increased cost
of health services.of health services.

8. 8
• An event or situation that could haveAn event or situation that could have
resulted in an accident, injury orresulted in an accident, injury or
illness but did not either by chance orillness but did not either by chance or
through timely intervention.through timely intervention.
NEAR MISSNEAR MISS

9. 9
Why should reportWhy should report
NEAR MISSNEAR MISS
Sentinel events
Adverse events
Near misses, other accidents
and occurrences
• They haveThey have
the samethe same
root causes,root causes,
as sentinelas sentinel
events, soevents, so
they shouldthey should
also bealso be
reportedreported

10. 10
SENTINEL EVENTSENTINEL EVENT
(DEFINITION)(DEFINITION)
• Any unexpected occurrenceAny unexpected occurrence
involving death, serious physical orinvolving death, serious physical or
psychological injury or the riskpsychological injury or the risk
thereof, and any event that mightthereof, and any event that might
cause embarrassment or risk to thecause embarrassment or risk to the
hospital with potential legalhospital with potential legal
implications and / or media inquiresimplications and / or media inquires
or coverage.or coverage.

11. 11
SENTINEL EVENTSENTINEL EVENT
• The phrase “or the risk thereof”The phrase “or the risk thereof”
includes any process variation forincludes any process variation for
which a recurrence would carry awhich a recurrence would carry a
significant chance of a serioussignificant chance of a serious
adverse outcome. Such events areadverse outcome. Such events are
called “sentinel” because theycalled “sentinel” because they
signal the need for immediatesignal the need for immediate
investigation and response.investigation and response.

12. 12
SENTINEL EVENTSENTINEL EVENT
(TYPES)(TYPES)
• Serious injury includes but is notSerious injury includes but is not
limited to:limited to:
– Unexplained or unexpected deathsUnexplained or unexpected deaths
or permanent loss of limb or functionor permanent loss of limb or function
that is not a result of the patient’sthat is not a result of the patient’s
medical condition.medical condition.

13. 13
– Surgery on theSurgery on the
wrong patientwrong patient
– Surgery on wrongSurgery on wrong
body partsbody parts
– Wrong procedureWrong procedure
SurgerySurgery
SENTINEL EVENTSENTINEL EVENT
(TYPES)(TYPES)

14. 14
SENTINEL EVENTSENTINEL EVENT
– Rape of a patient, staff or visitorRape of a patient, staff or visitor
– Infant abductionInfant abduction
– Unexpected death of full-term infantUnexpected death of full-term infant
– Child discharge to the wrong familyChild discharge to the wrong family
– Hemolytic blood transfusionHemolytic blood transfusion
– Patient suicide in the hospitalPatient suicide in the hospital

15. 15
– Retained instrument or spongeRetained instrument or sponge
– Intravascular gas embolismIntravascular gas embolism
– Maternal deathMaternal death
– Medication Errors leading to death orMedication Errors leading to death or
major morbiditymajor morbidity
– Patient’s fall resulting death orPatient’s fall resulting death or
severe dysfunction of body partsevere dysfunction of body part
SENTINEL EVENTSENTINEL EVENT

16. 16
SENTINEL EVENTSENTINEL EVENT
POLICYPOLICY
–All sentinel events requireAll sentinel events require
immediate investigation andimmediate investigation and
appropriate response by theappropriate response by the
corresponding committees. Allcorresponding committees. All
events should have an occurrenceevents should have an occurrence
generated report (OVR)generated report (OVR)

17. 17
SENTINEL EVENTSENTINEL EVENT
PROCEDUREPROCEDURE
1.1. Identification of a Sentinel EventIdentification of a Sentinel Event
2.2. Appointment of Task ForceAppointment of Task Force
3.3. Completion of Root Cause AnalysisCompletion of Root Cause Analysis
4.4. Committee ReportCommittee Report
5.5. Any report or documents generatedAny report or documents generated
by the Task Force are Confidentialby the Task Force are Confidential
and Privilegedand Privileged

18. 18
SENTINEL
EVENT
Immediate
Containment
Action
Reporting and
Notification
Investigation
and Review
Action Plan
& Monitoring
How to deal with a SentinelHow to deal with a Sentinel
Event/Adverse EventEvent/Adverse Event
Unit heads /
dept chairs
AP, Unit
heads / dept
chairs +
Customer
Service
Unit heads / dept
chairs, AP, Team +
Risk Management
Office
Unit heads /
dept chairs,
SQD + MQIO
Persons
accountable

19. 19
PURPOSE OF OVRPURPOSE OF OVR
• To provide a systematic hospital –To provide a systematic hospital –
wide identification mechanism aswide identification mechanism as
quality improvement tool for earlyquality improvement tool for early
detection and prevention ofdetection and prevention of
problems which have (or may have)problems which have (or may have)
an adverse patient outcome andan adverse patient outcome and
represent a potential hazard torepresent a potential hazard to
patients, visitors, volunteers,patients, visitors, volunteers,
students or employees.students or employees.

20. 20
PURPOSE OF OVRPURPOSE OF OVR
• To plan and implement correctiveTo plan and implement corrective
measures through identification bymeasures through identification by
root cause analysis.root cause analysis.
• To analyze the data and developTo analyze the data and develop
preventive measures periodically.preventive measures periodically.
• To help identify areas needingTo help identify areas needing
improvement or recognitionimprovement or recognition

21. 21
WHEN TO USE OVR:WHEN TO USE OVR:
• Injury to visitors or volunteersInjury to visitors or volunteers
while on the hospital premiseswhile on the hospital premises
• Any incident which is notAny incident which is not
consistent to routine patientconsistent to routine patient
carecare

22. 22
WHEN TO USE OVR:WHEN TO USE OVR:
• Occurrences not consistent withOccurrences not consistent with
routine operation of facility and /orroutine operation of facility and /or
adversely affects, threatens theadversely affects, threatens the
health or life of patient, visitor,health or life of patient, visitor,
employee, student or volunteer.employee, student or volunteer.
• Loss or damage to personal orLoss or damage to personal or
hospital property.hospital property.

23. 23
WHO SHOULDWHO SHOULD
REPORT?REPORT?
•EverybodyEverybody

24. 24
RESPONSIBILITIES:RESPONSIBILITIES:
• The employee who witnesses orThe employee who witnesses or
discoversdiscovers
–Immediate notification ofImmediate notification of
attending physician in case ofattending physician in case of
injury and Immediate Supervisorinjury and Immediate Supervisor

25. 25
RESPONSIBILITIES:RESPONSIBILITIES:
• Attending PhysicianAttending Physician
–Complete and document his/herComplete and document his/her
action (s) on the OVR formaction (s) on the OVR form
immediately upon carrying out hisimmediately upon carrying out his
examination and/or the requiredexamination and/or the required
treatment or care.treatment or care.

26. 26
RESPONSIBILITIES:RESPONSIBILITIES:
• Immediate SupervisorsImmediate Supervisors
–Consultation with the involvedConsultation with the involved
employee (s)employee (s)
–Resolution of problems shouldResolution of problems should
take place when possible withintake place when possible within
and between departmentsand between departments

27. 27
RESPONSIBILITIES:RESPONSIBILITIES:
• Immediate SupervisorsImmediate Supervisors
–Ensuring that all employees areEnsuring that all employees are
aware of OVR Reporting System;aware of OVR Reporting System;
how to report and the steps byhow to report and the steps by
steps procedure on how tosteps procedure on how to
complete the form.complete the form.
–Conduct immediate action andConduct immediate action and
follow up after the incident occursfollow up after the incident occurs

28. 28
RESPONSIBILITIES:RESPONSIBILITIES:
• Immediate SupervisorsImmediate Supervisors
–Document on the OVR the actionsDocument on the OVR the actions
taken and/or any correctivetaken and/or any corrective
measures, taken to prevent themeasures, taken to prevent the
recurrence of the eventrecurrence of the event
–Evaluates incident if meetsEvaluates incident if meets
sentinel event criteriasentinel event criteria

29. 29
RESPONSIBILITIES:RESPONSIBILITIES:
• Immediate SupervisorsImmediate Supervisors
– Forward the completed (original) OVRForward the completed (original) OVR
report form to the Total Qualityreport form to the Total Quality
Management office within 72 hours (3Management office within 72 hours (3
days) of the occurrencedays) of the occurrence
– Conduct any further investigation andConduct any further investigation and
document, report investigateddocument, report investigated
findings upon request of the Hospitalfindings upon request of the Hospital
Administration the QualityAdministration the Quality
Management CommitteeManagement Committee

30. 30
RESPONSIBILITIES:RESPONSIBILITIES:
•The Total QualityThe Total Quality
Management DepartmentManagement Department
–Monitoring all OVR for followMonitoring all OVR for follow
upup
–Trending and preparing aTrending and preparing a
monthly summarymonthly summary

31. 31
RESPONSIBILITIES:RESPONSIBILITIES:
•The Total QualityThe Total Quality
Management DepartmentManagement Department
–Submitting a quarterly reportSubmitting a quarterly report
to the Quality Managementto the Quality Management
Committee for discussion andCommittee for discussion and
what action can be done in thewhat action can be done in the
future to avoid recurrence.future to avoid recurrence.
–Upkeep the fileUpkeep the file

32. 32
RESPONSIBILITIES:RESPONSIBILITIES:
• The Safety OfficerThe Safety Officer
– Investigate all safety related incidentsInvestigate all safety related incidents
– Organize a review team of selectedOrganize a review team of selected
Safety Committee members toSafety Committee members to
investigate critical safety relatedinvestigate critical safety related
occurrencesoccurrences
– Document the results of investigationDocument the results of investigation
and corrective action taken on theand corrective action taken on the
OVR form and forwards it to the TQM.OVR form and forwards it to the TQM.

33. 33
OVR POLICYOVR POLICY
• Report the details of any occurrence,Report the details of any occurrence,
which has an impacts in the care ofwhich has an impacts in the care of
patient.patient.
• OVR Form will be initiated immediatelyOVR Form will be initiated immediately
after the incident. And submit it to yourafter the incident. And submit it to your
immediate supervisor within the currentimmediate supervisor within the current
work shift.work shift.
• All sections of the OVR form must beAll sections of the OVR form must be
completed and submitted to thecompleted and submitted to the
immediate supervisor within the currentimmediate supervisor within the current
work shift.work shift.

34. 34
OVR POLICYOVR POLICY
• The report will not be used toThe report will not be used to
criticize or blame the actions of thecriticize or blame the actions of the
staff involved.staff involved.
• Corrective actions shall be taken toCorrective actions shall be taken to
minimize risk of injury and adverseminimize risk of injury and adverse
outcomes. Corrective action (s) shalloutcomes. Corrective action (s) shall
be documented.be documented.
• The Occurrence report shall not beThe Occurrence report shall not be
placed in the medical record (Patientplaced in the medical record (Patient
File) nor in Employee File.File) nor in Employee File.

35. 35
OVR POLICYOVR POLICY
• Confidentiality:Confidentiality:
All OVR shall be handled andAll OVR shall be handled and
maintained in a confidentialmaintained in a confidential
manner with access to suchmanner with access to such
documentation restricted todocumentation restricted to
authorized individuals.authorized individuals.
OVR shall not be duplicated, withOVR shall not be duplicated, with
exception of the QM department,exception of the QM department,
when deemed necessary.when deemed necessary.

36. 36
OVR POLICYOVR POLICY
The information contained in theThe information contained in the
OVR form cannot and shall not beOVR form cannot and shall not be
used against any individual as theused against any individual as the
sole basis for disciplinary action.sole basis for disciplinary action.
The involved person’s MRN #The involved person’s MRN #
instead of his/her name will beinstead of his/her name will be
used on the OVR form.used on the OVR form.

37. 37
OVR POLICYOVR POLICY
 Hospital staff is not at liberty to discussHospital staff is not at liberty to discuss
the content of an OVR or the eventsthe content of an OVR or the events
and circumstances relative to theand circumstances relative to the
occurrence either with patient, visitoroccurrence either with patient, visitor
or other members of the staff, unlessor other members of the staff, unless
clarifying facts under investigationclarifying facts under investigation
with the proper authorities.with the proper authorities.
 Discussion of general issues on OVR forDiscussion of general issues on OVR for
instructional or educational purposesinstructional or educational purposes
with view to improving patient care iswith view to improving patient care is
however strongly encouraged.however strongly encouraged.

38. 38
The OVR form shouldThe OVR form should
not:not:
Be PhotocopiedBe Photocopied
Be Placed in Medical RecordBe Placed in Medical Record
Be DiscussedBe Discussed
Be given Personal OpinionsBe given Personal Opinions

39. 39
Do Not:Do Not:
Use the names ofUse the names of
involved/concerned person.involved/concerned person.
Use the content of the OVRUse the content of the OVR
against any individual foragainst any individual for
disciplinary action.disciplinary action.
Divulge any informationDivulge any information
written on the OVR form towritten on the OVR form to
unconcerned individuals &unconcerned individuals &
media.media.

40. 40
EQUIPMENTS /EQUIPMENTS /
FORMS:FORMS:
OccurrenceOccurrence
VarianceVariance
Report FormReport Form

41. 41
OVR FORMOVR FORM
DATE & TIME OF INCIDENT: _______________________
WARD/ROOM/DEPARTMENT: ______________________
DIAGNOSIS: _____________________________________
STATUS (CHECK ONE): ( ) IN-PATIENT ( ) OUT-PATIENT
( ) VISITOR
( ) EMPLOYEE ( ) OTHER (SPECIFY): _____________________
MEDICAL RECORD NUMBER: _____________
AGE: _____________SEX: __________________
NATIONALITY: __________________________
DATE & TIME RECORD INITIATED:
_________________________________________
__________________________________________
_
INTRAVENOUS RELATED
( ) Central Line
( ) Contrast Media Reaction
( ) Extravasate
( ) Occluded
( ) Precipitate
( ) Site Red/Swollen
( ) Tubing Leak
( ) Expired Fluid
( ) Additive Related
( ) Transfusion Reaction
( ) Other __________________
PROCEDURE VARIANCE
( ) Delay
( ) Missing Files/Notes
( ) Performed on Wrong Site
( ) Consent
( ) Patient Identification
( ) Wrong Patient
( ) Wrong Procedure
( ) Lost/Spoiled Specimen
( ) No Response
( ) Wrong File
( ) Procedure Cancellation
( ) Notes in Wrong File
( ) Inadequate/Inappropriate entry
( ) No Label/Addressograph
( ) Other
___________________________
BEHAVIOR
( ) DAMA
( ) Absconded
( ) Dissatisfied with Care
( ) Patient Behaivior
( ) Family/Visitor Behaivior
( ) Staff Behaivior
( ) Borrowed Medical Record Card
( ) Non-Compliance
HAZARD/SAFETY
( ) Burn
( ) Chemical Spill
( ) Electrical Shock
( ) Fire
( ) Gas
( ) Hazardous Waste
( ) Radiation Exposure
( ) Chemical Splash
( ) Water Spill
( )
Other________________________
SECURITY VARIANCE
( ) Damage/Loss of Property
( ) Drug Count Variance
( ) Drug Keys
( ) Prescription Alteration
( ) Security Problem
( ) Suicide Attempt
( ) Other ___________________
EQUIPMENT/SUPPLIES
( ) Electrical Problem
( ) Equipment Not Working
( ) Mechanical Problem
( ) Operator Not Qualified
( ) Wrong Equipment
( ) Missing Equipment
( ) Not Available
( ) Out of Stock
( ) Other ___________________
ARAR CENTRAL HOSPITAL
PART A – ADDRESSOGRAPH
OCCURRENCE VARIANCE REPORT
(NOT PART OF THE MEDICAL RECORD)
OCCURRENCE TYPE

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PART B 2-1 – DESCRIBE THE OCCURRENCE (STATE THE FACTS)
FACTUAL DESCRIPTION
…………………………………………………………………………………………………………………………………………….…..…
…………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………….…………
…………………………………………………………………………………………………………………………………..………………
Reported By: Name: ………….………………………..…..…. ID No. ………….… Dept. …………... Position………….……..
Witness By: Name: ………………………………………….. ID No. ……….…… Dept. …….……... Position………………...
IMMEDIATE ACTION: (PART B 2-2)
Physician Notified: ( ) YES ( ) NO ( ) NOT APPLICABLE
Did MD see patient: ( ) YES ( ) NO
If yes, investigation/s done: ( ) X-ray ( ) Suture ( ) Blood work ( ) Medication
Assessment/Diagnosis: (PART B 3-1)
………………………………………………………………………………………………………………………….………………..………
…………………………………………………………………………………………………………………………………….……..………
SEVERITY CODE (CHECK ONE) PART B 3-2
( ) Minor - no injury or minor treatment (i.e. abrasion; no increased length of stay; no increased level of care)
( ) Moderate - increased length of stay; increased level of care
( ) Major - temporary or permanent lessening of body functions
( ) Sentinel - catastrophic; death or major permanent loss of function
( ) Near Miss - potentially severe outcome
IMMEDIATE ACTION (PART C)
Action taken by initiating department Action taken by the responding department
……………………………………………………………..…………
…………………………………………………………………..……
…………………………………………………………………..……
……………………………………………………………..…………
……………………………………………………………..…………
……………………………………………………………..…………
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………………………………………………….…………………
………………………………………………….…………………
………………………………………………….…………………
………………………………………………….…………………
………………………………………………….…………………
Head of Department:
Date:
Head of Department:
Date:
TQM OFFICE COMMENT: PART D
…………………………………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………………………………
OVR FORM (PAGE 2)

43. 43
SUMMARY OFSUMMARY OF
LECTURE:LECTURE:• OCCOURANCEOCCOURANCE
• OVR (Definition)OVR (Definition)
• ADVERSE EVENTADVERSE EVENT
• VARIENCEVARIENCE
• NEAR MISS (& Why it should be reported)NEAR MISS (& Why it should be reported)
• SENTINEL EVENTS (Definition)SENTINEL EVENTS (Definition)
• “ ““ “ (Types)(Types)
• “ ““ “ (policy)(policy)
• “ ““ “ (Procedure)(Procedure)

44. 44
SUMMARY OFSUMMARY OF
LECTURE:LECTURE:• How to deal with sentinel/adverse eventHow to deal with sentinel/adverse event
• Purpose of OVR / When to use OVRPurpose of OVR / When to use OVR
• Who should report /responsibilitiesWho should report /responsibilities
(Employee, attending physician, immediate(Employee, attending physician, immediate
supervisor, TQM department, safety officer)supervisor, TQM department, safety officer)
• OVR policyOVR policy
• OVR form restrictionsOVR form restrictions
• OVR form sampleOVR form sample

45. 45