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Patient Care Variance Reporting Process

Introduction

Date of Last Review: 5/19/08
SME: Associate Director of Nursing


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

Purpose

The Patient Care Variance Report provides a mechanism for collecting detailed in-house information to study the quality of services provided at UTHCPC.

Who

All patient care staff use this report.

When

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

With injury

Without injury

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

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.

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.

5

As warranted, the physician documents findings and treatments in the medical record (e.g. physician orders, progress notes).

6

The Risk Manager completes Section 5, Category C to include:

Corrective action

Implementation plans

Quality/Risk issues

Recommendations

Distributing the form

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

Adds any comments (documents resolution status or action plan)

Signs the form and sends it to the Department Director or Director of Nursing for review prior to the end of the shift

3

The Department Director/Director of Nursing:

Reviews variance for trends and initiates appropriate corrective actions

Identifies improvement opportunities

Forwards form to Risk Manager within 24 to 48 hours of receipt

4

The Risk Manager:

Reviews variance for trends and initiates appropriate corrective actions

Identifies improvement opportunities

Forwards form to Data Management

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)

Related standards

Related to regulatory standards

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Harris County Psychiatric Center University of Texas Health Science Center