OCCURRENCE
VARIANCE REPORT
DR ABDUL WAHEED
TQM DIRECTOR
BASICS OF PATIENT SAFETY
Patient safety is a framework of organized activities that
creates cultures, processes, procedures, behaviours,
technologies and environments in health care that
consistently and sustainably
Lower Risks
Reduce the Occurrence of Avoidable Harm,
Make Error Less Likely and
Reduce its Impact when it does Occur.
Some Stats from WHO
4 out of 10 patients are harmed in Primary and
Ambulatory Care.
Medication Errors cost an estimated $42 Billion.
134 Million adverse events occur each year in
hospitals, leading to 2.6 million deaths
DEFINITIONS
AN OCCURRENCE
Is an unusual event which adversely affects or threatens
the health or life of patient, visitor, employee or trainee which
involves loss or damage to personal or hospital property.
An occurrence also includes any event that might otherwise
result in any adverse situation or violate the code of
conduct or a claim against the organization
OCCURRENCE VARIANCE REPORT
Is an internal form used to document the details of the
occurrence/event and the investigation of an occurrence and the
corrective actions taken.
NEAR MISS
Is an event or situation that could have resulted in an
accident, injury or illness, but did not, either by chance or through
timely intervention.
INCIDENT
event or circumstance that harmed or has the
Is an
potential to harm a person or a property in relation, resulting from
human behavior and/or system failure
ADVERSE EVENT
unintended harm
Is an event that results in to the patient by
an act of commission or omission rather than by the underlying disease or
condition of the patient.
SENTINEL EVENT
unexpected occurrence involving
A “Sentinel Event” is an
death or serious physical or psychological injury,
or the risk thereof, not related to the natural course of a patient’s illness or
underlying condition.
OVR FORM
WHEN TO USE
Incident which is not consistent to routine patient care.
Occurrence not consistent with routine operation of facility
and /or adversely affects, threatens the health or life of patient, visitor,
employee, student or volunteer.
Loss or damage to personnel or hospital property
Who should report ?
Everyone
How to Report ? OVR Form
OVR PROCESS
INCIDENT OCCURS
MITIGATE THE HARM
OCCURRENCE VARIANCE REPORT IS FILLED BY THE PERSON
WITH IN 24
WITNESSED/ AFFECTED BY THE OCCURRENCE
HOURS
SIGN OFF BY DIRECT MANAGER
SENT TO TQM&PS DEPARTMENT FOR LOG
TQM&PS FORWARDS THE OVR TO CONCERNED DEPARTMENT/S
THE DEPARTMENT MANAGER DETERMINES
THE CASE SEVERITY
INCIDENTS IN GREEN AND YELLOW ZONE INCIDENTS IN AMBER AND RED ZONE
THE RESPONDING DEPARTMENTS TAKES ACTION POTENTIAL SENTINEL EVENTS
MANDATORY REPORTABLE EVENTS
ARE REPORTED TO MOH WEBSITE
OVR SUBMITTED IN TQM&PS WITH ACTION REPORT
FEEDBACK TO REPORTER ESCALATE INADEQUATE • SENTINEL EVENT FLOW CHART
RESPONSE • RCA
RESPONSE TIME FOR RESPONDING
DEPARTMENT
YELLOW AND GREEN ZONE: Complete Investigation within 5 working
days and Send the feedback to the Quality and Patient Safety
Department.
AMBER ZONE: Complete Investigation within 10 working days and
Send the feedback to the Quality and Patient Safety Department and to
the Risk Register.
RED ZONE: Complete RCA and action plan within 14 working days and
add to the Risk Register
IMPROVED PROCESS OF OVR
RISK REGISTRATION WITH FOLLOW UP OF ALL RESPONSES UP TO 3 YEARS
PROMPT FEEDBACK BY EMAIL
CASE TO CASE, EVALUATION & RE EVALUATION
GUIDELINES AND SUPPORT TO RESPONDING DEPARTMENTS
email
OVR NUMBER OVR-376-2021
TITLE PATIENT SMOKING INSIDE WARD
RISK LEVEL HIGH
REASON VALIDITY VALID
PROCESS FORWARD TO FMS DIRECTOR
ACTION DISCUSSION IN COMMITTEE MEETING
STATUS CLOSED
SENTINEL EVENTS
List of Sentinel Event 13- Death of Full Term Infant
1- Wrong Patient 14- Rape
2- Wrong Site Surgery 15- Workplace Violence
3- Hemolytic Blood Transfusion Reaction 16- Fire
4- Suicide in an Inpatient Unit 17- Suicide of Staff, Visitor, Watchers anywhere
5- Retained Instruments or a Sponge on property
6- Intravascular Gas Embolism 18- Critical Equipment Breakdown or Faliure
7- Major Medication Error Leading to Death or Major When in Use
Morbidity 19- Unintended Collapse of any Building or
8- Maternal Death Structure Under Construction or Alteration
9- Infant Discharged to Wrong Family 20- Collapse or Overturning of any Load Bearing
Part of any Lift or Lifting Equipment When in Use
10- Infant Abduction
11- Unexpected Death
21- Equipment Malfunction Leading to Death or
Major Morbidity
12- Unexpected loss of a limb or a Function
TQM AND PATIENT SAFETY ARE DETERMINED TO PROVIDE SAFE ENVIRONMENT
IN OUR ORGANIZATION
PLAY YOUR ROLE IN PATIENT SAFETY
DO NOT HESITATE
THANK YOU
