1. Event & Disclosure Reporting
Module 15-B
Event & Disclosure Reporting
Presented by:
Caroline Swinton, MSN, RN
Director, Risk Management &
Patient Relations

2. EVENT REPORTING
Intended to promote a safe and healthful environment for patients, visitor, employees, medical staff and volunteers.
Prompt reporting provides a mechanism to improve quality of care by preventing similar events and identifying opportunities.

3. EVENT REPORTING
An event report must be generated for any unanticipated happening that is not consistent with the routine care of a patient and/or the routine operation of the facility.
Examples – falls, medication related(wrong dose), IV (wrong solution), pressure ulcer and loss of property.

4. Event Reporting iVOS Event Reporting System (ERS)
is located in the following:
Clinical Tunnel
Starfish Folder
A paper Event Report for may be used and must be delivered to the Risk Management or Patient Relations Departments.

5. iVOS Event Report

6. SAFE HARBOR PROVISIONS
All events must be reported immediately. If any employee completes and submits an event report within 48 hours of becoming aware of the event, there will be no disciplinary action taken; however, additional education or training for the involved individual may be required, if warranted under all the circumstances. An event report must be submitted by an employee involved in an event even if another employee has previously submitted a report of the event. This safe harbor provision does not apply to action or requirements of regulatory bodies.

7. SAFE HARBOR PROVISIONS
Safe Harbor provision does not apply to protect any individual if:
The acts or omissions of the reporting employee , giving rise to the event, are the result of criminal activity or activity outside an employee’s job description or license.
Action demonstrates a willful reckless disregard for the safety of patients, employees, medical staff or visitors.

8. SAFE HARBOR PROVISIONS
Safe Harbor provision does not apply to protect any individual if:
It is clear that an employee can’t practice in a safe manner, after having been provided appropriate education.
At the time of the event the employee was under the influence of alcohol or illegal drug use.

9. SAFE HARBOR PROVISIONS
The determination as to whether the reporting of an event is exempt from the safe harbor under one of these exceptions will be made in accordance with appropriate human resource policies and procedures with input from hospital leadership and Dignity Health Legal Department.

10. Just Culture
The facility supports a non punitive reporting environment which is based on the “Just Culture” objective model for dealing with human errors and breeches.
Each event reported will be analyzed based on the decision paths for allocating responsibility to either the system or the individual, based upon duty and not based upon severity of outcome.

11. DISCLOSURE REPORTING
Disclosure -Communication to patients or families of information regarding test, treatment or surgical intervention.
Unanticipated Outcome/Event-An adverse result that differs from what was anticipated to be the result of a treatment or procedure.

12. DISCLOSURE REPORTING
Take necessary action to mitigate the harm to the individual that may be caused by the unanticipated outcome.
It is the responsibility of all employees and physicians to report any unanticipated outcome immediately to their immediate supervisor and the facility Risk Manager.
Complete an event report.
Participate in any investigation (as directed) initiated to determine the cause of the event that may prevent future like occurrences.

13. DISCLOSURE REPORTING
Once it has been determined that an unanticipated outcome has occurred disclosure is necessary to patient or representative.
The treating Physician, Risk Manager and Director/Manager will determine the appropriate time for disclosure.
All three individuals or designees will participate in the disclosure.
Only these individuals or designees are allowed to disclose information regarding the event.