Description

Complete, narrative account of the event.

On-Screen Instructions

Briefly summarize the circumstances leading up to the event. Include the following:

• Contributing factors

• The role those contributing factors played

• The system practices and processes involved

• If appropriate, please also briefly describe the relevant patient clinical progress

Include enough information so that someone unfamiliar with the event could easily understand how the event happened.

Field Type

Text (Maximum length: n/a)

Guide for Use

What information should I include in the Event Summary?

Providing a clearly understandable description of an adverse event ensures the information shared can be used for learning beyond the walls of the facility that submitted the report. In the report’s “Event Summary”, summarize the sequence of activities and circumstances leading up to the event in a way that someone unfamiliar with the event could easily understand. Include details about identified contributing factors along with decisions and other rationales that influenced the occurrence of the event.

Strong complete accounts include the following elements:

• Sequence of actions and relevant surrounding circumstances/conditions

• System-level contributing factors directly associated with the event

• Only clinical information relevant to understanding the event

The following examples are based on actual reports received by OPSC and contain all of the elements of a strong event summary:

Example 1
Per his morning routine, a 68 year old resident came to the nurses’ station and waited to get his morning medications. The medication aide was busy preparing medication for another resident. When the aide finished, she began preparing the waiting resident’s medications. The aide was rushing because a new admit was expected in the next hour, she still had to finish the morning med pass, and several other residents had gathered to receive their medications on the way to breakfast. The aide grabbed the resident’s insulin and prepared a syringe. After administering it, she realized that she had accidentally injected the rapid-acting insulin (which the resident received at a different time of day) instead of the ordered long-acting insulin. The resident became hypoglycemic and was transported to the hospital for observation.

Example 2
On 3/16 a 63 yo male was transferred to [hospital] with chronic kidney disease requiring hemodialysis. He had been treated for SOB and CHF. Creatinine currently potassium levels elevated. This am, following IV diuretics without significant urine output and rising potassium, patient was sent for hemodialysis; temporary HD placed in groin. Procedure followed central line placement checklist.

On 3/19 CVL-Perm HD placed in neck. On 3/20 CVL-Ablation performed for atrial flutter. There was a delay in ablation case start after site prep completed. Checklist used for ablation procedure, but not for earlier line placement as it has not been required in all settings. On 3/21 patient experienced chills, hypotension, lethargy, WBC=23.0 (previous WBC on 3/20 was 7.8). 3/21 positive blood cultures x2 for MSSA, no infection identified at other site—CLABSI. 3/22 Patient expired, severe sepsis (patient/family did request comfort care).
“Central Line Placement Checklist” did not include Chlorhexidine manufacturer recommendations for moist sites such as inguinal fold. [Medical] director feels staff would benefit from other training.

Example 3
A 63 year old male with iron deficient anemia and heme positive stools was seen in clinic and scheduled for an EGD and colonsocopy. Patient’s medical history included dysrhythmias (pacer/implanted defibrillator), CHF, CAD, OSA, obesity, and difficult intubation. The patient was assessed in the clinic to be an ASA 3. Cardiac clearance was obtained from the cardiologist along with a defibrillator letter regarding magnet usage and reprogramming.

During EGD patient began coughing. Suction was administered, pt. began to desat quickly. Airway assistance provided (chin lift, O2 up to 10 L via mask, nasal airway pieced). Rhythm was erratic. Pt. became blue. Ambu bag used to administer breaths with O2 at 15L/min. His defibrillator was noted to fire, he appeared to be in pulseless electrical activity. CPR was started and patient achieved a good pulse. After multiple tries, the patient was intubated and transferred to hospital via emergent transport. Following a 3 day hospital stay, patient was discharged home.

History