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Healthcare Professionals / Progress Notes / Practice of Medicine / From equipment malfunctions to patient falls: questions and answers on event reports

 
From equipment malfunctions to patient falls: questions and answers on event reports
8/4/2017

From Michele Crum, RN, MSM, CPHRM, Manager, Risk Department; Deborah K. Riley, M.D., CPPS, Patient Safety Officer; and Lisa A. Brosey, RN, CPPS, Director, Patient Safety

 

LG Health uses event reports as the means of reporting all events.
 
An event report should be entered when:

  • A visitor or patient falls

  • A patient receives or almost receives an incorrect medication

  • A patient must return to a procedural area unexpectedly

  • Equipment malfunctions

  • You have any concern regarding patient care

Who enters the event?
The employee or staff member who discovers or witnesses the event enters the information into an event report form, which is located in the Policies & eForms section of StarNet. Each staff member is personally responsible for reporting adverse events and potential events to prevent future adverse outcomes. Failure to report a serious event will result in the reporting of any licensed health-care professional to his/her respective state professional licensure board in accordance with Pennsylvania's Medical Care Availability and Reduction of Error Act (Act 13).
 
What is entered?
The facts of what occurred, in as much detail as needed for others to understand what occurred. Even if the issue was a near miss, this is considered a good catch and helps us to evaluate methods to prevent the event from occurring at another time.
 
When should I enter a report?
As soon after the event as is safe for patients but before you leave at the end of your shift.  The details will be fresh in your mind and more accurate.
 
Why must I report events?

  • To provide a factual account of the event

  • To strengthen and improve the process of patient care

  • To enhance patient safety initiatives

  • To track and trend events for more proactive Risk Management activities

  • To meet state and federal regulatory requirements

What happens after the report is submitted?
The report will go to the manager of the department where the event occurred, as well as the risk manager who supports that department.  The event is reviewed, and when able, action steps are put into place to prevent the event from occurring again.  All events involving medications also go to Pharmacy to review.  An investigation occurs by the manager and risk manager. If you would like feedback on an event, speak with your manager or Risk Management on next steps. 
 
If you have questions regarding this announcement or any other issues related to patient safety, please contact the Patient Safety Office or leave a suggestion or other concern 24/7 on the voicemail Patient Safety First Line, 717-544-4040.

  • Patient safety tip: The Joint Commission has released its latest “Do Not Use” List of Abbreviations. Click here for more information.

 
 

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