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– WEST VIRGINIA – Public and Private Policy Medical Errors and Patient Safety
Definitions
The voluntary West Virginia program utilizes a proprietary system for adverse event data collection and analysis. Quantros, Inc. is the company that supplies the software system, and the software reflects its proprietary design rather than West Virginia's design goals.
The following classification scheme of Occurrence type is available on the Quantros, Inc. Demonstration Site under ‘Occurrence Report....Occurrence Type’ in the dropdown list. Additions or revisions to the Occurrence Type scheme that appeared on the website in 2005 are indicated in red.
In an earlier website, each major Occurrence Type category included explanations, which were accessible at ‘Occurrence Report....Help....FAQ’. However, these explanation are no longer available, but they are reproduced below.. These explanations below give an idea of the software categorization schema that is used in this software product.
Quantros, Inc. Occurrence Type Classification
Occurrence Type Category |
Explanation |
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1. |
Admission/Discharge/Transfer Related |
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Examples include:
- • Missing ID Card/Bracelet
- • Newborn Footprint sheet incomplete
- • Admission delayed
- • Missing Medical Record file
- • No available beds
- • COBRA issues
- • Readmission issues
- • No bed at transfer facility
- • Admission or D/C forms not complete
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2. |
Adverse Drug Event (Reaction) |
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This Occurrence Type if reporting an incident that is related to a patient having an adverse drug reaction. This could be true even if the drug wasn't administered. For instance, if the medication was ordered and the patient told the nurse prior to receiving it that they are allergic to the medication, you could still report the incident as an Adverse Drug Event and a Near Miss.
The information that is required before one can complete the form is:
- • The drug that was involved and whether or not it was administered.
- • Whether or not the reaction was responsible for admission at this time.
- • If the drug was a Non-Formulary drug.
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3. |
IV / Blood / Transfusion Related |
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This Occurrence Type is for reporting an incident that is related to IV transfusions or Blood transfusions. The Occurrence Type title has been changed since 2005. |
4. |
Clinical Diagnosis and General Treatment Related |
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This Occurrence Type is for reporting an incident that is related to any clinical diagnosis events (such as the wrong diagnosis, a mismatch of pre and post diagnosis, etc.) or general treatment related incidents (such as the wrong tests ordered, reaction to a treatment, missing test results, patient missed treatment, etc.).
With this occurrence type one needs to indicate whether the occurrence being report is Clinical Diagnosis or General Treatment. Once designated, the web page expands with questions that relate only to the designated selection.
Note: As with all occurrence forms, the more information that is provided in the form will be produced in Analysis reports. |
5. |
Clinical Setting Environment of Care Related Events |
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This Occurrence Type is for reporting an incident that is related to the clinical settings. The Occurrence Type title has been changed since 2005. With this occurrence type one needs to indicate the nature of clinical setting that is related to this incident. Options are:
- • Unanticipated Transfer to Higher Level of Care
- • Unplanned Readmission
- • Patient Suicide Event
- • Patient Seclusion Event
- • Level 5 Restraint Event
- • Unanticipated Patient Death
- • Alleged Physical Abuse
- • Alleged Sexual Abuse
- • Alleged Sexual Misconduct
- • Alleged Harassment
- • Discharge Against Medical Advice
- • Patient AWOL
- • 'Other', if your advent is not listed above.
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6. |
Codes (Emergency Situations) |
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This Occurrence Type is for reporting an incident that is related to a Code or other emergency related situation. |
7. |
Communication/Notification Related |
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This Occurrence Type is for reporting an incident that is related to a communication incident. For instance verbal communication that was misunderstood, written communication that may have led to a wrong exam being ordered, or any verbal or written notification issues. |
8. |
Device/Equipment/Product Related Event |
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This Occurrence Type is for reporting an incident that is related to devices or equipment. For instance if a portable X-Ray machine broke down while taking an x-ray at the patient's bedside causing uncomfort to the patient. |
9. |
Fall/Accident Related |
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This Occurrence Type is for reporting an incident that is related any type of falls, whether it be a patient, visitor, or employee. To complete this form, one needs to report the cause of the fall, the state of the person prior to and after the fall, etc. |
10. |
Medication Error |
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This Occurrence Type is for reporting an incident that is related to a medication error. This could be an incident where the wrong medication was ordered, the prescription was missing, or the medication was dispense with the wrong dosage. |
11. |
Missing/Lost/Damage Property |
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This Occurrence Type is for reporting an incident that is related to any lost, missing, or damaged property. |
12. |
Nutrition Related |
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This Occurrence Type is for reporting an incident that is related to nutrition. For instance, wrong dietary orders, allergic reaction to food, etc. When selecting this occurrence type, one is prompted to select the nature of the occurrence. Options are:
- • Allergic Reaction to Food
- • Nutritional Supplement Issues
- • Diet Delivery Error Issues
- • Tube Feeding Error Issues
- • TPN Error Issues
- • Infant Nutritional Issues
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13. |
Other Occurrence Type
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This Occurrence Type was not included in the 2005 website and has been added since that time. This category of occurrences probably reflect miscellaneous occurrence types not included in other Occurrence Types. |
14. |
Patient Complaints |
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This Occurrence Type is for reporting an incident that is related to any type of patient complaint whether it be regarding their nursing care, housekeeping accommodations, billing, or ancillary services. |
15. |
Skin Integrity
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This Occurrence Type was not included in the 2005 website and has been added since that time. Undoubtedly, this section would include spaces for decubitus ulcers and/or burns that might be sustained during healthcare. |
16. |
Specimen Related |
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This Occurrence Type is for reporting an incident that is related to specimen issues, such as mislabeling of the specimen, unusable, handling errors, etc. With this occurrence type, one needs to indicate the nature of the specimen related occurrence. Options are:
- • Incomplete/Inconclusive Test
- • Test Could Not be Performed
- • Additional Procedures Required
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17. |
Surgery/Invasive Procedure Related |
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This Occurrence Type is for reporting an incident that is related to a surgical procedure or an invasive diagnostic test. This could be chosen if a wrong procedure was performed, a break in a sterile technique occurred, a wrong reading on an X-ray, excessive blood loss, etc. |
18. |
Treatment Related |
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This Occurrence Type is for reporting an incident that is related to a treatment whether it be in Surgery, Anesthesia, Emergency, OB/GYN, or Med Surg. |
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- NEAR MISS: Near misses are errors that almost happened, but were prevented prior to an actual occurrence could happen. Near misses share many of the same characteristics as major occurrences.
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