PURPOSE: To define the policy and expectations regarding ...



313943335000Faculty Practice OrganizationPolicy No.Patient SafetyPS.2.02Policy Title: Reporting of Safety Events, Complaints and GrievancesOriginal Date of Issue: November 2013Reviewed Date/s:3/2017Revised Date/s:3/2017PURPOSE: To define the policy and expectations regarding the internal reporting of patient complaints, grievances, unsafe conditions and safety events involving patients, visitors and/or faculty occurring within the ColumbiaDoctors Ambulatory practice sites. POLICY STATEMENT:APPLICABILITY: FPODEFINITIONS:Patient Safety and Quality Improvement Act of 2005 (PSQIA): The Patient Safety and Quality Improvement Act of 2005, Public law 109-41, 42 U.S.C. 299b-21-b-26. Patient Safety and Quality Improvement. Final Rule (Final Rule): The Department of Health and Human Services (HHS) adopted rules and the framework to implement aspects of the PSQIA, for which the PSOs as well as the providers (hospitals, doctors, and other health care providers) may create, handle, aggregate, and analyze information reported to/from a PSO on a privilege and confidential basis. The Final Rule was developed (effective January 19, 2009) by a number of organizations and agencies such as AHRQ,Patient Complaint is any complaint that can be resolved to the patient’s satisfaction at the time of the complaint by staff present. Verbal patient complaints that cannot be resolved at the time of the complaint by staff present, is postponed for later resolution, is referred to other staff or requires investigation or further actions for resolution are considered to be a grievance. Verbal communication includes telephonic communication.Patient Grievance is any written complaint or verbal complaint that cannot be resolved to the patient’s satisfaction at the time of the complaint by staff present. Such complaint may be made by the patient or by the patient’s representative regarding the potential for or actual patient care, safety, abuse or neglect. Written complaints are considered to be grievances. Written communication includes e-mail. If the grievance is based upon the lack of interpreter services or any form of discrimination after it is entered in to Clarity immediate notification by phone must be made to Patient Safety Director, 51 Audubon Ave, New York, NY, 10032 (212) 305-4572, CDSafety@CUMC.Columbia.edu, who has been designated to coordinate the efforts of ColumbiaDoctors to comply with Section 1557. Patient Safety Event: an event, incident, or condition that could have resulted or did result in harm to a patient. A patient safety event can be, but is not necessarily, the result of a defective system or process design, a system breakdown, equipment failure, or human error. Patient safety events also include adverse events, no-harm events, close calls, and hazardous conditions, which are defined as follows: ? An adverse event is a patient safety event that resulted in harm to a patient. ? A no-harm event is a patient safety event that reaches the patient but does not cause harm. ? A close call (or “near miss” or “good catch”) is a patient safety event that did not reach the patient. ? A hazardous (or “unsafe”) condition(s) is a circumstance (other than a patient’s own disease, process, or condition) that increases the probability of an adverse event. Provider: An individual or entity licensed or otherwise authorized under State law to provide healthcare services including hospital, nursing facility, comprehensive outpatient rehabilitation facility, home health agency, hospice program, renal dialysis facility, ambulatory surgical center, pharmacy, physician or health care practitioner’s office, long term care facility, behavior health residential treatment facility, clinical laboratory, or health center; or a physician, physician assistant, nurse practitioner, clinical nurse specialist, certified registered nurse anesthetist, certified nurse midwife, psychologist, certified social worker, registered dietician or nutrition professional, physical or occupational therapist, pharmacist, or other individual care practitioner; or any other individual or entity specified in regulations promulgated by the Secretary 1 Clarity Safety Zone? is the web based event reporting and data collection program used by the MCIC/ECRI and Clarity PSO for reporting, reviewing and commenting upon events. It is the main process for transmitting information from the PSES to the PSO. Good Catch a safety event that almost occurred but was actively prevented from reaching the involved patient, employee or visitor and caused no harm Near Miss an unplanned event that by chance did not result in injury, illness or fatality but has the potential to do so in the future if left unaddressed Root Cause Analysis is a process for identifying the factors that underlie variation in performance while focusing on systems and processes rather than individual performance Safety Event an unplanned event that reached the patient or visitor which may or may not have resulted in injury, illness or fatality (i.e. medication omission, unwitnessed falls) Sentinel Event is a patient safety event (not primarily related to the natural course of the patient’s illness or underlying condition) that reaches a patient. Sentinel events in the ambulatory care setting include but are not limited to the following: An event resulting in an unanticipated death or major/permanent loss of function not related to the natural course of the patient’s illness or underlying condition; harm that is either permanent or severe and temporary2 and/or The event is one of the following (even if the outcome was not death or major permanent loss of function not related to the natural course of the patient’s illness or underlying condition): Invasive procedures, including surgery, performed on the wrong patient, on the wrong site, or the wrong procedure; Unintended retention of a foreign object in a patient after surgery or other invasive procedures; Prolonged fluoroscopy exposure with cumulative dose >1,500 rads to a single field or any delivery of radiotherapy to the wrong body region or >25% above the planned radiotherapy dose; Hemolytic transfusion reaction involving administration of blood or blood products having major blood group incompatibilities (ABO, Rh, other blood groups);Abduction of any patient receiving care, treatment, or services;Rape, assault (leading to death or permanent loss of function), or homicide of any patient receiving care, treatment, or servicesRape, assault (leading to death or permanent loss of function), or homicide of a staff member, licensed independent practitioner, visitor, or vendor while on site at the health care organization Fire, flame, or unanticipated smoke, heat, or flashes occurring during an episode of patient careUnsafe Condition: any condition that poses a threat to safety such as environmental, behavioral or process related. PROCEDURE/IMPLEMENTATION:1. As soon as reasonably possible after becoming aware of a safety event (no later than 24 hours), near miss, good catch or unsafe condition, the staff or faculty member who has knowledge of, was involved in, or witnessed the safety event or unsafe condition is responsible and has a duty to report the event by entering the factual information into Clarity. 2. Sentinel Events require immediate telephonic notification to the Patient Safety Director via cell phone (347) 978-6356 in addition to promptly reporting in Clarity. The Patient Safety Director coordinates the following: a. A formalized team response that stabilizes the patient, discloses the event to the patient and family, and provides support for the family as well as staff involved in the event b. Notification of ColumbiaDoctors leadership as appropriate c. Immediate investigation d. Completion of a comprehensive systematic analysis for identifying the causal and contributory factors e. Strong corrective actions derived from the identified causal and contributing factors that eliminate or control system hazards or vulnerabilities and result in sustainable improvement over time policy is up to the policy author’s discretion.f. Time line for implementation of corrective actions g. Systemic improvement3. For all other patient safety events a root cause analysis (RCA) to be conducted within forty-five calendar days of becoming aware of any event that is either a reportable (sentinel, NYPORT) event or one which if left unaddressed could lead to significant patient harm or medical error. 4. No-harm events, close calls, and hazardous conditions are tracked and used as opportunities to prevent harm, in accordance with ColumbiaDoctors PSES and Patient Safety Plan’s process for responding to patient safety events that do not meet the definition of sentinel event 5. Clarity uses pre-established logic to notify designated individuals that a potential or actual safety event has been submitted for their review. 6. Designated Reviewers have been assigned for each department and are responsible for reviewing events and providing follow up information as needed and in a timely manner but in no circumstances later than the date requested in Clarity. 7. The Patient Safety office aggregates safety event data and submits summary safety reports to the Quality and Patient Safety Committee and the Board of Governance on a regular basis. DOCUMENTATION AND MONITORING:Identify any required documentation or monitoring activities associated with the policy such as reports, audits, chart reviews and/or site visits/inspections.REFERENCES:Agency for Healthcare Research and Quality Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) 2017 National Patient Safety Foundation RESPONSIBILITY:The title of the individual or role responsible for developing, reviewing and revising the policyRELATED POLICIES & PROCEDURES:PC 1.04 Adverse Event Reporting for Office Based Surgery Policy.PC 1.3.1 Compliance with Section 1557 of the Affordable Care Act (ACA)REVIEWED/APPROVED BY/ DATE:ColumbiaDoctors Quality and Patient Safety Committee; June 26, 2019Appendices: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download