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