Northwest Michigan Surgery Center



Date Reviewed: April 15, 2013

Occurrence Reports (Adverse Incident Reporting)

POLICY

An adverse medical incident or error is one that causes, potentially or actually, patient or employee injury. It involves unintentional, unexpected harm to a patient or employee arising from any aspect of healthcare management.

Definition of an adverse incident includes, at a minimum, the following:

• an unexpected occurrence during a healthcare encounter involving patient death or serious physical or psychological injury or illness, including loss of limb or function, not related to the natural course of the patient’s illness or underlying condition

• any process variation for which a recurrence carries a significant chance of a serious adverse outcome

• Events such as actual breaches in medical care, administrative procedures or other events resulting in an outcome that is not associated with the standard of care or acceptable risks associated with the provision of care and service for a patient

• an unexpected occurrence while working that involves employee death, physical or psychological injury or illness

• circumstances or events that could have resulted in an adverse event

Anytime such an incident occurs (thus placing a patient or staff member at risk) an Occurrence Report needs to be completed in order to evaluate causes, eliminate recurrence and work toward minimizing risk

PROCEDURE

1. An Occurrence Report is completed by the employee who witnesses or is

involved in the occurrence.

If an occurrence is a transfer or return to OR, the Occurrence Report should be

turned over for data entry and documentation in Vision as a variance within 24

hours. For an occurrence of any other type, go directly to #2 below.

Note: Date of service cancellations are not considered adverse events and thus

do not warrant an Occurrence Report write up. Reference SOP entitled “Scheduling – Cancelled Appointments” for documentation requirements.

2. The Occurrence Report should be turned in immediately to the employee’s direct supervisor for review. Supervisor should provide follow up documentation and forward to Clinical Director for review and sign off.

3. Once complete, the report should be turned over the Administrative Assistant to be

logged, and then provided to Chief Executive Officer (CEO) for further review.

4. The CEO will evaluate the event and determine the need for Medical Director

review/intervention.

5. If Medical Director review is warranted, the relevant patient chart will be

accessed and a clinical chart audit performed. Occurrence Report will then be submitted to Medical Director.

6. Medical Director will evaluate occurrence and related documentation to

determine if issue merits Medical Executive Committee (MEC) oversight. If so,

occurrence will be presented at next scheduled meeting of the MEC.

7. MEC will review designated occurrences, documenting findings and evaluation

on Peer Review form. On the basis of these assessments the Medical Director

may reach out to the individual providers to address issues of concern.

Guidelines for Completion

When filling out the Occurrence Report, please include:

1. Titles instead of names (example: surgeon stated patient’s condition was

improving, instead of Dr. Jones stated…).

2. If reported on multiple subjects within one form, be sure to address the resolution of

each item listed.

3. When doing post-op follow-up on patients hospitalized for infection, the form entitled

“Investigation of Post-Operative Infection” should be completed in detail and

accompany the Occurrence Report

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