adverse events by compliancedoctor

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									Sentinel Events/Adverse Events             Policy #

                                           Effective:


                                           Reviewed:

                                           Revised:



POLICY: (ADVERSE EVENT LAWS CHANGED IN 2013 FOR SURGERY CENTERS WITHIN THE STATE
OF CALIFORNIA, THEREFORE, THE LAW SUSPERSEEDS ANY FACILITY POLICY-SEE LETTER
FROM STATE MEDICAL BOARD TO FOLLOW THIS POLICY).

Events, meeting indications for intensive assessment, are to be reported to the
Nurse Manager, who will be responsible for coordinating the intensive assessment
process. In rare instances the Medical Director may determine that the event
does not require intensive assessment and refer the event for prompt review (for
example, if the event involves a single individual).

Definitions:

1.    Adverse Event:
      Is an outcome or circumstance with significant patient injury or
      impairment to the patient.

      Examples include:

               1.1 Significant adverse drug reaction;
               1.2 Major discrepancy between preoperative and postoperative
                   diagnosis;
               1.3 Significant adverse anesthesia reaction;
               1.4 Significant deviation from a historical statistical norm.

2.    Sentinel Event:
      Is an unexpected event occurrence involving death or serious physical or
      psychological injury or the risk thereof. It is an adverse event of a
      severe and urgent nature. Such events are often red flags for potential
      litigation, associated with drastic physical or psychological injury to a
      patient, and are often indicators of system and/or personnel problems that
      pose a threat to future patients.

      Examples include:

               2.1   Operation on the wrong limb;
               2.2   Death due to a medication error;
               2.3   Major error found at autopsy;
               2.4   Adverse event associated with public criticism;
               2.5   Event associated with a lawsuit or the threat of a lawsuit;
               2.6   Event associated with open interpersonal conflict or
                     disruptive behavior affecting patient care.




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3.    Intensive Assessment Team:
      Consists of three members representing Medical Staff leader and nursing
staff. Medical and/or management staff with knowledge related to the event
will be added to the    team. The Intensive Assessment Team will conduct a
root-cause analys
								
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