Case Study

Journey of an Occurrence Report

Occurrence reporting is the foundation of a healthcare risk management program. Without a standard process, occurrence reports can easily get lost in the twists and turns of the “rabbit hole.” Scripps Memorial Hospital has developed a thorough risk management program, under the guidance of the senior director of quality. Let’s follow a hypothetical incident process through the rabbit hole and meet all of the necessary characters along the way.

Caption: From left to right (top row) Virginia Rich, Tamara Winkler, Julia Gollobit, Kathleen Reilly; (bottom row) Julie Salazar, Jennifer Smith, Michelle Nelson

Scenario:  Alice, an 88-year-old patient of Dr. Hatter, was scheduled for a total knee replacement. Alice anxiously awaited this important day and finally checked into the hospital with her friend and surrogate decision maker, the White Rabbit. The surgery was performed without a hitch. During a routine x-ray of Alice’s knee after surgery, the radiologist noted a small, round metallic object in Alice’s post-op film. Apparently, one of Dr. Hatter’s hat sequins from had fallen into the surgical field.

Dr. Hatter appropriately disclosed the findings to Alice and the White Rabbit. Alice decided to return for the removal of the foreign object. The OR staff dutifully submitted an occurrence report to ensure proper follow-up of this unexpected event. The next day Alice was discharged to her home in Wonderland in good condition.

Down the Rabbit Hole – The Beginning
Clinical Risk Specialists (CRS) are responsible for the timely review, analysis and follow-up of all occurrence reports generated throughout the hospital. The CRS determines the level of risk to the organization and prioritizes which occurrences may need further drill downs in the form of a root cause analysis. The CRS also looks for trends in data with the goal of preventing significant events from occurring.

The risk to the patient and organization related to a retained foreign object is significant. The CRS determined a root cause analysis was needed to identify the factors that may have contributed to the retained foreign object. A thorough and credible root cause analysis would include everyone who was involved in Alice’s surgery:

  • the surgeons, anesthesiologists and staff members documented as being in the surgery
  • subject matter experts such as the surgical services educator, infection control manager and policy administrator to provide insight on best practices and assist in implementing process changes
  • administrators and managers to assist with resource allocation and authorize any important changes that may be recommended.

The CRS works with the managers to develop an action plan that will address the root causes with meaningful and lasting solutions. The root-cause investigation has privileged protection from discovery in potential civil actions in order to encourage the advancement of process improvement and healthcare quality. While some follow-up of root-cause investigation may be confidential, other process changes or feedback can and should be shared with all of the involved parties.

Which Way do we go from Here?
The CRS invited to tea the RN project managers, liaisons for physician peer review. It was thought that indeed the Professional Practice Review Committee (PPRC) should thoroughly review the case to determine if there may be questions of clinical judgment, appropriate diagnosis, technique, responsiveness or policy compliance with Dr. Hatter’s care of Alice. The PPRC members discuss and determine, from a physician perspective, what action should be taken to prevent a recurrence of the event. The Professional Standards Committee (PSC) reviews cases that involve physician professional behavior, citizenship and communication. The PSC implements steps for resolution of behavior.

In the case of Alice, the PPRC determined that Dr. Hatter did not follow the policy requiring removal of his hat nor did he cover his hat or put on a surgical cap prior to Alice’s surgery. Dr. Hatter was sent a letter from the PPRC outlining the case issues, a summary of the committee discussion and adjudication of the occurrence. The outcomes of all cases are entered in a database and monitored for recurring events and patterns in provider care. Physicians are credentialed biennially and information from both committees is included in the credentialing process. This process establishes qualification and assesses status for ongoing privileges, allowing the physicians to practice at our facility.

Similar to the federal legal protection of the occurrence report and root cause analysis as well as state laws protecting specific information from discovery, the reviews performed in the PPRC and PSC meetings are also privileged and confidential.

Through the Looking Glass
Patients and family members are encouraged to share their feedback regarding their care and service received at our facility. We often receive positive comments and forward those to the staff or physicians being recognized. When feedback identifies opportunities for improvement, the patient advocate works with the department managers and physician leaders to review the grievance and work toward resolution.

In compliance with the Centers for Medicare and Medicaid Services for grievances, the hospital has seven business days to send an acknowledgment letter and 30 days to send a closing letter, which summarizes the concerns identified and any action taken to ensure the event does not occur again.

Our patient Alice decided to Yelp about her concerns related to the retained foreign body and the costs associated with the additional surgery required to remove Dr. Hatter’s sequin from her knee. This social media information was sent to the patient advocate who worked with the CSRs and the billing department to resolve Alice’s concerns. Alice later amended her Yelp posting, praising the quick and helpful follow-up service she had been provided.

It Was All a Dream
What we learned from this scenario is that a standardized process for the management of occurrence reports helps to identify valuable opportunities for improvement through root cause analysis, peer review and patient satisfaction feedback. Each component can play a vital part in a successful risk management program for your hospital.

The authors would like to recognize Tamara Winkler, senior director of Performance Improvement, Risk and Infection Control, for her leadership and expertise.

Scripps Memorial Hospital Quality Team Article Contributors:
Tamara Winkler MBA, RN, CPHQ-CPHRM
Jennifer Smith BSN, RN, CPHRM
Ginny Rich RN, CPHRM
Julia Gollobit BSN, RN
Kathleen Reilly, RN
Michelle Nelson MBA


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