Reporting of Unanticipated Adverse Events

Objectives Identify when to report an unanticipated adverse event Describe how to report an unanticipated adverse event

Definition Adverse Event – any unanticipated happening that is not consistent with the routine care of a particular patient and/or the routine operation of the facility. An adverse event may also involve a visitor, employee, volunteer, student or Physician.

When to Report an Unanticipated Adverse Event Examples of unanticipated adverse event: Falls Medication Related (wrong dose) IV (wrong solution) Pressure Ulcers Leaving Against Medical Advice (AMA) Elopement Disruptive Behavior Patient Self Injury Loss of Property

How to Report an Unanticipated Adverse Events If an unanticipated adverse event is detected the following should be followed: Contact the attending physician, manager and house supervisor immediately. Complete an Event Report via the iVOS Event Reporting System located in the Clinical Tunnel. Only the physician, risk manager, nurse manager or designee will be responsible to disclose the event to patient or legal representative. An appointed hospital designee will be responsible to report the event to the appropriate regulatory agencies.

Where to Find iVOS Event Reporting System (ERS) ERS is located in the following: Clinical Tunnel Starfish Folder

A paper Event Report form may be used and must be delivered to the Risk Management or Patient Relations Department. If you have any questions completing an event report, contact your charge nurse, manager, supervisor or the risk management.