Administrative Alert - After Hours/Weekends

Introduction

Date of Last Review 04/2/07
SME: Director of Nursing

After 5:00 p.m. daily and on weekends UTHCPC staff report any untoward event or significant occurrence potentially resulting in an adverse event involving patients and/or staff.

Significant events

The following are significant events that require administrative alert:

All potential high risk or sentinel events, see procedure on Sentinel and High Risk Events

All elopements

Significant visitor occurrences

Regulatory body contacts

Hazardous/safety events

Significant agency/community contacts

Other events that could be significant

Administration notification

Employees report as follows:

Who is responsible...	Tasks to perform...
Staff	Contacts her/his manager or nursing supervisor and verbally reports Fills out Patient Care Variance Report or Occurrence Report as appropriate See related procedures: Patient Care Variance Reporting Process Occurrence Reporting Process
Manager/Nursing Supervisor	Notifies the Administrator on-call see Verbal notification Forwards the written report (i.e. e-mail) the next working day to the appropriate Administrator/Director/Director of Nursing, Manager and the Risk Manager as appropriate

Verbal notification

Verbal notification to the Administrator on-call occurs within 60 minutes of the event occurrence.

Exception: Sentinel and high risk events are reported immediately

Administrator on-call duties

The Administrator on-call has the following duties:

Confers as needed with the appropriate Manager/Director/Director of Nursing the morning of the next working day from the incident

Is responsible for notification and follow-up of the incident and action taken with the following:

Administrator

Medical Director

Appropriate manager/director

Forms

Patient Care Variance Report
Occurrence Report

Related standard

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.