Risk Management

What is an “event”?

An unplanned occurrence, which has the potential for injury whether or not an injury actually occurs, when the occurrence is not consistent with the routine care of a patient, routine service of a department or the operation of the hospital or entity.

    Examples include:

  • Falls
  • Medication errors- even if corrected before reaching the patient
  • Treatment errors
  • Patient injury due to medical equipment
  • Safety and security issues
  • Missing property

What is a “serious event”?

   Any situation involving a patient that:

  • Results in death
  • Compromises patient safety
  • Results in unanticipated injury requiring additional services

What’s a “sentinel” event?

  • Deaths due to injuries, suicide or unusual circumstances
  • Deaths or serious injuries due to medication errors
  • Surgery on the wrong patient/body part
  • Rape or complaint of patient abuse

When to report?

  • Complete an event report by the end of a shift through the “PSN” (Patient Safety Net) system icon, located on all PC desktops (this is an electronic event report tool)
  • Submit to the manager and to Risk Management
  • “Serious events” are reported immediately to Risk Management 

Who should report?

  • Anyone who sees or discovers an event must report it
  • You are our eyes and ears

Who to notify?

  • Supervisor/Nurse Manager
  • Administrator On-Call (off-hours and weekends)
  • Risk Management 215-456-6396
  • Physician for any follow up, if appropriate
  • Protecting Event Reports

What’s the purpose of reporting?

  • Identify problems in our hospital system, not to punish employees
  • Find potential risks
  • Take steps to prevent future problems

All Event Reports are confidential

  • Do not:
    • Discuss in a public area
    • Place or reference in a medical record
    • Make copies
    • Focus on the facts, not opinion, conclusions or accusations