Patient Care Variance Reporting Process (Online and Paper Version)

Introduction

Date of Last Review: 5/19/08

Revised: 5/13/2011
SME: Director of Performance Improvement

Introduction

This topic provides information about completing and distributing the Patient Care Variance Report.

Policy:

Patients' accidents/incidents are reported and documented as soon as possible after the patient accident/incident occurs.

Purpose

To facilitate timely, accurate, and complete documentation of all patient accidents/incidents.

To provide necessary timely interventions for patients involve accidents/incidents.

To provide a mechanism for collecting detailed in-house information to study the quality of services provided at UTHCPC.

All patient care staff use this report.

Definition

For purposes of this policy an occurrence is defined as any event that is not consistent with the routine operation of the hospital that may have led to an error, accident, or situation that could have, or has resulted in an injury to a patient.

Scope

This policy applies to all clinical staff on all shifts.

When

A Patient Care Variance Report shall be submitted via on-line or paper as soon as possible by those who observed or discovered the event. The Online Patient Care Variance Report can be accessed through the HCPC Web Forms.

Use of above form to report the following occurrence types:

Occurrence Types
Injury Abrasion Bite Bruise Burn Contusion Laceration Needle stick Sprain Strain Other (specify)	High Risk Event Alleged sexual activity AWOL Code blue Elopement Elopement attempt Medical emergency Seizure activity Sexual aggression Suicide attempt Other (specify)
Personal Belongings Damage/Loss Money Clothes Wallet Other (specify)	Falls (Use Fall Variance Form) With injury Without injury Witness/Unwitnessed
Miscellaneous AMA/discharge Refusing discharge Refusal of treatment
High risk events of the above occurrences, see Sentinel and High Risk Events Sentinel events, see Sentinel and High Risk Events Other, provide description Note: When the incident does not fall into the categories listed above, or does not involve a patient, use the Occurrence Report form.

Reporting sentinel/high risk events

Follow these steps to report sentinel or high risk events:

Who	Action
Staff	Immediately contacts her/his manager or nursing supervisor and verbally reports high risk events prior to filling out the Patient Care Variance Report Go to Completing the form
Manager/Nursing Supervisor	After notification by staff, immediately contacts the Administrator on duty or on-call and verbally reports the incident. If after 5:00 p.m. daily and on weekends: Fills out an Administrative Alert form See related procedure Administrative Alert - After Hours/Weekends Go to Distributing the form

Completing the form

This table describes the process for completing the Patient Care Variance Report form by an assigned staff member:

Stage	Description
1	Stamps the patient's addressograph card on the top, right-hand corner of the form. (Paper Version*)
2	Completes Sections I-V (only categories A & B under Section 5) of the Patient Care Variance Report form to include: General information Occurrence type Brief description Immediate action Proactive implementations Referral to other involved departments
3	Staff member completes the "MD Implementation/Recommendations" under Section IV as applicable.
4	Documents a progress note in the patient's medical record. Note: Do not refer to the form in the patient's medical record. * The language used to describe an occurrence/event should be objective, factual and timely.
5	As warranted, the physician documents findings and treatments in the medical record (e.g. physician orders, progress notes).
6	The Director of Performance Improvement completes Section 5, Category C to include: Corrective action Implementation plans Quality/Risk issues Recommendations

Distributing the form (Paper Version)

This table describes the process for distributing the Patient Care Variance Report form:

Stage	Description
1	Staff member submits the completed variance form to the Department Manager/Nursing Supervisor before the end of her/his shift
2	Department Manager/Nursing Supervisor accomplishes the following: Reviews the report, concurring with or correcting the category(ies) of the variance and staff members actions * The form may not be copied, circulated, or deleted. Adds any comments (documents resolution status or action plan) Signs the form (* Paper Version *) and sends it to the Department Director/Manager/Chief Nursing Officer for review prior to the end of the shift
3	The Department Director/Manager/Chief Nursing Officer: Reviews variance for trends and initiates appropriate corrective actions Identifies improvement opportunities Forwards form to Director of Performance Improvement (* Paper Version *) within 24 to 48 hours of receipt
4	Director of Performance Improvement: Reviews variance for trends and initiates appropriate corrective actions Identifies improvement opportunities Forwards form to Data Management (* Paper Version *) Quarterly, reports safety-related data to Safety Committee

References

Patient Care Variance Report form
Sentinel and High Risk Events
Administrative Alert form (for reporting high risk events after normal working hours)

Fall Variance  

Related standards

CMS- Conditions of Participations-Performance Improvement

The Joint Commission-Provision of Care Treatment and Services, Performance Improvement

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