Description
Determination of the nursing facility event type that is being reported.
On-Screen Instructions
Select all that apply.Please note: “Poisoning” should be submitted as “Other.” “Food allergy” and “medication allergy” should be submitted as “Medication or other substance.” The event type “Treatment related” has been split into “Contractures,” “Dehydration,” “Diabetic coma,” “Fecal impaction,” “Intravascular embolisms related to IV therapy,” and “Pressure ulcer.”
Field Type
Checkbox (multiselect)
Responses
OPTION ONE: Answer options with content (definition and/or inclusions, exclusions)
Add an anchor in front of the H1 “Responses” heading and name the anchor “Top.”
Include a table of contents, which should be limited to the answer option headers and displayed as a list.
Add a dividing line macro below the table of contents.
Answer option 1
Answer Option Anchors and Headings
Each answer option gets an anchor and an H2 heading in sentence case.
[If there is a very important piece of information about this answer option - like that it is always considered a serious event - display that between the answer option header and definition using a warning panel macro. It can also include an “include excerpt” macro, like this one with standard text for inherently serious events.]This event type is always considered a reportable event, regardless of level of patient harm.
[Definition goes here.]
Definition
Copy/paste the “description” text from the data dictionary.
Includes
Excludes
Inclusions and Exclusions
Add a page layout of two equal columns below the definition. Inclusions go in the left column, exclusions in the right.
Event-Type Specific Questions |
Additional Support |
Event-Type Specific Questions
If the answer option triggers additional question, add a content by label macro to display all pages that share the form_field label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. The macro goes in a single cell table with a light gray fill. The title above the macro should just be table text, bold (no header level), that reads: Event-Type Specific Questions.
Additional Support
If the answer option is associated with an “faq” item, add a second row to the table and paste in a content by label macro to display all pages that share the faq label plus the relevant answer option label, possibly plus the relevant segment label, depending on the situation. Macro should have title “Additional Support” in the table cell, above it, as with the “Event specific questions” macro.
Return to Top Links
Below the page layout or Content by Label macro(s) (if relevant), include a link to the “top” anchor to take the user back to the responses table of content.
Dividing Line
Add a dividing line after the “return to top” link and before the next answer option, or the next section (probably “Additional Guidance”).
Guide for Use
If “Other” is selected, a text box for a description will also appear.[If there is a adequate information about each answer option, this section may not be necessary. But if there is guidance that isn’t about the specific responses, then this is where you would put it, including instructions for how to use this field. If there is no guidance, you can use the “No additional guidance” excerpt: No additional information provided.]
Sometimes an event seems to fit two or more event types. When completing a PSRP report, how do I determine the correct event(s)?
Even though an event may seem to fit more than one type, the Oregon Patient Safety Commission (OPSC) encourages participants to identify the primary event from which subsequent events resulted when completing a Patient Safety Reporting Program (PSRP) report. Identifying the primary event helps focus an investigation and determination of the root cause and increases the likelihood that action plans resulting from the investigation will truly prevent recurrence (see Scenario 1, below).
Not every PSRP report has a primary event; sometimes there are multiple, independent events that affect the same patient at the same time (see Scenario 2, below). Some are obviously related, but have different causes (e.g., the wrong medication is administered, resulting in respiratory distress, and the resuscitation equipment breaks). Other events may be more difficult to identify. For example, medication events can have multiple opportunities for a “good catch” before they reach the patient, making them seem like multiple events in retrospect (see Scenario 3, below). When determining the primary event, investigators should ask, “If one of these events had been prevented, would the others have still occurred?”
Scenario | Primary Event Type | Discussion | |
|---|---|---|---|
| 1 | A patient is misidentified, taken to the operating room, and the wrong procedure is performed. | Incorrect patient | Incorrect patient should be reported as the primary event. The incorrect procedure was a result of the patient misidentification. |
| 2 | In mixing three medications for topical administration, the first medication is added correctly, only half of the desired dose of the second medication is added, the third medication is omitted, and the container is left unlabeled. | This is three medication events:
| This is three medication events: (1) the patient received an incorrect dose of one medication, (2) the patient received no dose of another medication, and (3) the bottle was not labeled. There is no unifying primary event—they each happened independently. If the patient gets an incorrect dose of one medication and has another omitted because the bottle was labeled incorrectly, then it is one event because the incorrect dose and omission are direct results of the bad label (see Scenario 3, below). |
| 3 | Patients A and B are supposed to each get a mixture of the same three medications, though the proportions of the medications are different. The medications are both mixed, then the labels printed. In applying the labels, they are switched and Patient A and B each receive the other’s medication. | Incorrect/incomplete labeling | This is one medication event, incorrect label, because the subsequent incorrect medication would have been avoided if the bottles been correctly labeled. |
History
Start Date | Spring 2012 |
|---|---|
End Date | n/a |
Change History | n/a [Month yyyy: brief description of change] |