Safety Zone Event Reporting

Management and Prevention of events

for Patients and Employees

As a High Reliability organization, event reporting provides us with:

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A way to identify patient and staff safety, quality and compliance concerns so that Aspirus can be proactive in preventing harm

Information on how are we affecting the patient experience

Process improvement opportunities

Why do we have Patient Event tracking?

Detect Issues

Discover Patterns

Develop Solutions

Improve

What Can be Reported Through Safety Zone

What Do I Report

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For Patient Safety: events that impact Patient Care & Safety –including Incidents, Good Catches, & Unsafe Conditions

For Patient Complaints: any complaint brought forward by patient or family

For Employee Health: any employee injury

For Compliance: potential HIPAA violation, other compliance concern, seek guidance or ask a question.

How do I Report

On Aspirus intranet, choose ‘system info’

Drop Down allows key options; choose ‘safety zone’

Reporting Form

You can report an event for anywherewithin the Aspirus system.

When filling in the report, the * notes a required field

Patient Information for Wausau, Langlade, Medford and Michigan

Input the patient’s

P-number from the Clinic Chart

OR

Medical Record Number (MRN) from the hospital chart

Then click on Lookup Demographics this will auto populate the form

Patient Safety-Event Types

Event Types Behavior

Blood Transfusion Adverse Reaction

Blood Transfusion Incident

Clinical Equipment

Clinical/Patient Care and Therapy

Falls

Infection Control

Invasive Line/Tubing

Laboratory Tests/Specimens

Medication Events

Newborn/Birth Events

Operative and Invasive Procedures

Radiation-Imaging/Therapy

Security/Facility

Complaint/Service Recovery-Event Types

Complaint/Service Recovery Event Types

Billing

Communication

Coordination of Care

Customer Service

Diagnostic/Procedure

Facility

Food

Medical Staff Care

Noise

Nursing Care

Patient Rights

Personal Property

Types of Safety Concerns

Incident: A patient safety event that reached the patient, whether or not the patient was harmed

Good Catch: A patient safety event that did not reach the patient / events that almost reached the patient but were identified, caught or stopped before patient contact.

Unsafe condition: Any circumstance that increases the probability of a patient safety event; includes a defective or deficient input to or environment of care process that increases the risk of an unsafe act, care process failure or error, or patient safety event. An unsafe condition does not involve an identifiable patient.

Safety Concern Examples

Incident Patient Fall-any unplanned decent to the floor (assisted or unassisted)

Pressure Ulcer-Skin tear

Wrong site surgery

Patient receives the wrong medication-wrong dose-wrong route

Left Against Medical Advice(AMA)/Left without being seen (LWBS)

Good Catch RN notices that medication sent up by pharmacy is the wrong dose

and calls for correct dose before giving to the patient.

Unsafe Condition Housekeeper mops stairs and forgets to place the "wet floor” caution

sign

Missing controlled substance (narcotics)

Tell a Story

What Occurred

Stick to the facts- what happened, who it happened to and who else was present.

If there are any questions about the event/circumstances, we can contact those involved or who witnessed the event.

What was done

Provide what action was taken at the time of the event to ensure that follow-up and future actions can be put on the appropriate timeline.

Always Click the at the bottom of the form Clicking Save completes the report, you will not be able to access it again

Safety Zone will time out after 59 minutes You can choose to be ‘anonymous’ when reporting

What if….

…you are injured or find yourself in an unsafe condition?

The following slides are to assist you in reporting

Employee Events in Safety Zone.

Employee Health/Injury

Employee Health Event Types

Blood and Body Fluid Exposure (i.e. needle stick injury, blood splash to the eye)

Employee Illness (i.e. Pertussis)

Employee Injury (i.e. strain, sprain, slip & fall)

Ergonomic Consultation

Unsafe Work Environment (Slips/Trips/Falls, Safe Patient Handling, TB/BBP, Grounds and Facilities)

What Employee Incidents Should You Report?

Unsafe Work Environment: Any circumstance that increases the probability of an employee injury event, and/or an event that did not cause injury and did not require medical treatment.

• Report all perceived risks, or unsafe work environments• full sharps container• Unmarked wet floors • Broken or malfunctioning equipment• Employee not using or misusing safe patient handling equipment

Actual Injury, Illness or Blood & Body Fluid Exposure: Any incident that causes harm to an employee in the workplace. The actual injury, illness, or exposure may result in first aid, medical treatment, time off of work, modified duty work, and continued monitoring until situation is resolved or at end of healing.

Employee Incident Reporting Process

Immediately report incident to your supervisor/manager/team lead.

The employee should contact Employee Health, and submit their event in Safety Zone as soon as an incident occurs.

Injured or potentially injured employees are to complete the event online at the Aspirus Safety Zone portal immediately and no later than the end of their shift.

Supervisor may be required to complete the event for the employee if the employee is severely injured and not capable of doing so.

The above steps should be completed prior to seeking medical treatment unless the event is serious and emergent.

The employee will be contacted within in 1 business day by an Employee Health Services Representative to review and evaluate Employee event and Return to work status.

Employee must communicate with Employee Health regarding any work restrictions, follow up appointments, or other relevant details of your incident.

Employee Incident Reporting Process

Immediately report incident to your supervisor/manager/team lead

Enter event into Safety Zone-Employee Health/Injury Form

Follow-up per site specific protocols.

Medical Evaluation Process

Emergency:

If a work-related injury needs emergency medical evaluation you should proceed directly to the Emergency Department.

Non-Emergency: If a work-related injury is not emergent, it is suggested that Employee’s seek medical attention at:

• Aspirus Walk-in.

• Aspirus Occupational Health

• Personal Care Provider

• Emergency Department, general work after hours

In the State of Wisconsin, we cannot direct medical care, however, it is suggested that they seek appropriate medical attention as noted above.

For all incidents involving a blood or bodily fluid exposure you must be seen in the Emergency Department for medical evaluation. NOT EVERYWHERE

*In the state of Michigan, during the first 28 days of treatment, the employer has the right to direct care to a provider of their choice. Following the 28-day treatment period, you may change providers upon notification to the worker’s compensation carrier and Employee Health.*

Injury and Return to Work

• Employee’s must present a current return to work slip if they seek medical attention.

• RTW slips are maintained in SZ

• SZ promotes and enables Employee Health Representatives to manage your Event, to assure timely management and return to work services.

Compliance Form

Completing the Event Form

Event Type Event Date and Time Entity What occurred – it is important for the

compliance department to get an accurate picture of what happened in order to know how to address the event.

Who was present – if there is question about the event circumstances we can contact those that are involved or witnessed an incident.

What was done - it is important to provide the action that was taken immediately so that the follow up and future action can be put on the appropriate timeline.

Your name and contact information is not required, however, lack of contact information my limit our ability to investigate and resolve the issue. All contact information will be kept confidential.

Myths about Reporting

It is bad to have your name on Safety Zone Reports

Aspirus encourages reporting as the events provide opportunities for improvement.

Reporting is a waste of time because the information goes nowhere

Each report is reviewed by the Quality Department, Clinical Risk Management, and leaders of the department involved and anyone else who can help make changes.

Data is analyzed on a regular basis throughout the system to identify systemic trends and opportunities to improve.

Reporting Example

• Water shut off without notice to dialysis staff that interrupted the treatment of numerous patients

• Report filed in Safety Zone

• Head of Facilities and Nursing Director met to discuss plan for improvement to ensure this does not happen again

• New process for contractor work on buildings implemented

• No new events reported!!!!!

Who Do I Contact for Help?

For assistance with the Patient Safety or Complaints area of the portal: Safetyzoneadmn@aspirus.org

Who Do I Contact for Help? (cont.)

• For assistance relating to Employee Health/Injury, please contact the Employee Health Nurse at 715-847-2785.

• For assistance relating to Compliance, call Aspirus Compliance Hotline:

• 1-800-450-2339 or

• 1-715-847-2166