Occurrence Reporting Process

Introduction

Date of Last Review 6/5/07
SME: Director Of Performance Improvement

Occurrence tracking and reporting is part of UTHCPC's Performance Improvement Plan.

Purpose

This report is used to help identify areas needing improvement or recognition.

When to use

Use the Occurrence report form to document:

Injury to visitors or volunteers while on the premises (Send these occurrences to the Safety Compliance Coordinator in Room 3A-30 Note: Employee injuries are reported on the Supervisor's First Report of Injury form and send to Health Case Management/Infection Control Nurse Room 3A28)

Other occurrences that cannot be documented on another approved report form

Who reports

The following report occurrences using the Occurrence Report:

Employees

Medical staff

Students

Patients Note: The occurrence report is for reporting purposes only. Do not place in a reporting patient's medical record.

Visitors

What to report

Report any of the following:

Compliments

Complaints

Other miscellaneous incidents

If significant occurrences happen after 5:00 p.m. or on weekends, see procedure Administrative Alert - After Hours/Weekends

Distribution

Distribute copies of the form as follows:

Occurrence reporting

This table describes the occurrence reporting process:

Stage	Description
1	Informant obtains a blank Occurrence Report form from one of the following: Reception desk Any department manager Nursing Supervisor Any unit Online ( Please make copies for the recipients at the bottom of form if you use online version)
2	Informant completes the form following the directions on the back of the form.
3	Informant keeps the pink copy of the report and uses this table to determine to whom to give the other two copies: WHEN the informant is a... THEN s/he gives the other two copies to... Visitor The staff at the reception desk Result: Reception desk staff forwards the copies to their department manager Patient A unit nurse Result: The unit nurse forwards the copies to the Director for Nursing Staff member or other His/her department manager
4	The department manager keeps the yellow copy and forwards the white copy to the appropriate Assistant Administrator within 48 hours.
5	The Assistant Administrator: Notifies the appropriate department manager(s) of the report Ensures follow-up on the report Reports trends/patterns to the Performance Improvement Coordinating Council
6	The department manager(s) designated by the Assistant Administrator investigate and report their findings to: Assistant Administrator Applicable hospital committees/departments, as needed

Related standards

The Joint Commission : Improving Organization Performance

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