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
|
|
|
| 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
|
|
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:
|
|
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
If you have questions regarding the content of this site please contact the
Policy and Procedure Committee. If you
experience any technical problems please contact the MIS Department.
