/policies/,/policies/administrative/,/policies/administrative/uw-health-administrative/,/policies/administrative/uw-health-administrative/legal-services/,

/policies/administrative/uw-health-administrative/legal-services/422.policy

201611319

page

100

UWHC,UWMF,

Policies,Administrative,UW Health Administrative,Legal Services

UW Health Event Reporting (4.22)

UW Health Event Reporting (4.22) - Policies, Administrative, UW Health Administrative, Legal Services

4.22

Page 1 of 5


Administrative (Non-Clinical) Policy
This administrative policy applies to the operations and staff of the University of Wisconsin Hospitals and
Clinics Authority (UWHCA) as integrated effective July 1, 2015, including the legacy operations and
staff of University of Wisconsin Hospital and Clinics (UWHC) and University of Wisconsin Medical
Foundation (UWMF).
Policy Title: UW Health Event Reporting
Policy Number: 4.22
Effective Date: November 11, 2016
Chapter: Legal Services
Version: Revision
I. PURPOSE
To provide a mechanism to identify areas of system vulnerability, achieve efficiency and effectiveness of
operations, decreased adverse events and improve the delivery of patient care.
II. POLICY ELEMENTS
A. All reported events shall be confidential as part of the Wisconsin Health Care Quality
Improvement Act (“WHCQIA,” found at Wis. Stats. Secs. 146.37 and 146.38).
B. It is the responsibility of staff to detect and promptly report events in accordance with this policy
using the Patient Safety Net (PSN) on-line event reporting system.
C. The focus of this event reporting mechanism is system improvement and recognition of processes
that contribute to error and not fault finding. This policy recognizes that staff continue to be
accountable for their actions. Organizational work rules apply.
1. Frontline reporters are encouraged to identify themselves so that adequate follow-up from
the manager can occur in a timely manner or, if necessary, to garner additional
information.
2. Information regarding the reporter will be treated as confidential.
3. Staff will not be reprimanded or treated unfairly for reporting an event.
4. If staff feel they are being treated unfairly, staff should report this to their manager/direct
supervisor, or director.
5. If staff is unable to address this concern with their manager/direct supervisor or director,
staff can contact the UW Health Program Director of Organization Performance and
Patient Safety.
D. For the purpose of achieving efficiency and effectiveness of operations, and minimizing the
potential for re-occurrence, event reporting information will be evaluated regularly by the UW
Health Patient Safety Committee, and other safety committees as appropriate.
III. DEFINITIONS
PATIENT SAFETY NET (PSN): PSN is a web-based event reporting system that is available on U-
Connect (Quick Links) and via Health Link.
EVENT: Includes all of the following event types:
1. adverse event - Any undesirable variation in a health care delivery process or
environment that results in patient, staff or visitor harm

Page 2 of 5

2. potential adverse event – Also known as a “near miss” or “close call”, this is an unsafe
condition or an undesirable variation in a health care delivery process or environment that
does not reach the patient/staff/visitor
3. sentinel event - An unexpected adverse event involving death, major permanent loss of
function, sensory, motor, physiological, or intellectual impairment not present on
admission requiring continuing treatment or life-style changes, or other serious physical
injury
PERFORMANCE IMPROVEMENT (PI): A formal approach to the analysis of organizational
processes and systematic efforts to improve them.
STAFF: Any individual working in the UW Health organization including physicians, advanced practice
professionals, residents, fellows, medical students and all employees.
IV. PROCEDURE
A. Identification and reporting of events.
1. Any staff member suspecting an event has resulted or has the potential to result in harm
to a patient, visitor or staff member, should report the event electronically via PSN.
Frontline reporters do not require a login to use the program – it can be accessed from
any shared workstation.
2. Information entered should be factual (not opinion), complete and accurate, focusing on
the variation in the process.
3. Do not reference in the medical record that a PSN report has been filed.
4. PSN should not be used for placing blame on other individuals.
5. For adverse events that require medical attention:
a. Staff should immediately notify the responsible medical care team.
b. A description of the event, treatment provided and the patient’s response to
treatment should be documented in the medical record.
6. Disclosure of unanticipated outcomes to the patient/family.
a. Whenever an event results in patient harm, the responsible physician/designee
will clearly explain the outcome to the patient, and when appropriate, to the
family.
b. Risk Management or Patient Relations should be contacted for assistance in
disclosing an unanticipated outcome. Refer to the Disclosure of Unanticipated
Outcomes to Patient/Family Policy 4.45.
B. Certain event types will require additional reporting and action.
1. Actual or potential sentinel events should be immediately reported to the Risk
Management Department.
2. Biohazardous exposures should also be immediately reported to your manager and
Employee Health.
a. When Employee Health is closed, seek consultation with the Emergency
Department or Urgent Care Center as advised by Employee Health.
3. UW Health property damage should be reported immediately to Risk Management and
Facilities/ Engineering Services.
4. Completion of a PSN for a staff injury does not automatically refer the event to workers
compensation. Please remember to complete the appropriate worker’s compensation
form, available on U-Connect.
5. Although staff are encouraged to report safety and quality of care concerns via PSN and
management, concerns can also be shared with The Joint Commission Office of Quality
Monitoring (1 (800) 994-6610 or complaint@jointcommission.org.


Page 3 of 5

C. PSN Event Report Notification
1. The PSN system alerts managers when an event is reported based on event location,
event type or harm score.
2. The report is available immediately on-line for review.
3. The event evaluation team is notified of all events with high harm scores. Safety leaders
and other safety committees also receive notification of these events.
4. The PSN system will also send applicable cases to appropriate individuals or committees
such as Environment of Care and Medication Safety, for evaluation and possible follow
up.
D. Manager Review and Follow-up
Managers will promote a healthy culture of safety where staff members feel comfortable
reporting. Areas with a healthy culture of safety see larger volumes of reported events, which
ultimately leads to a safer environment for patients, visitors and staff. PSN is a great resource that
allows the manager to understand the safety of the care that is being provided in their area,
understand trends and vulnerabilities, and make changes before a sentinel event occurs.
Note: For the purpose of event follow-up, a “manager” may be the manager of a particular area,
the manager of an ancillary area, any individual consulted for input, and/or a committee
representative or their designee.
1. All events require follow-up by the manager(s).
2. Best efforts to review a PSN report within 72 normal business hours of submission
should be made to determine if a report is complete and accurate. At a minimum, where
the event occurred should be correct.
3. Best efforts to document follow-up findings on the Manager Review page within 30 days
of submission. (Note- this is a shared page for all managers to use)
4. Refer the event to other managers for review through the event reporting system, if
needed.
5. Identify systems issues that require organizational attention and refer them to event
evaluation team.
6. Support staff involved in events. They may suffer a heavy emotional burden when an
unanticipated adverse event has occurred. Any staff may request and receive confidential
personal support from the Employee Assistance Program (EAP). The UW-Madison EAP
program is available for University physicians and university medical school staff.
7. Contact frontline reporters who have requested follow-up.
8. Managers should work with their physician dyad where applicable to:
a. Identify and remedy system issues and
b. Share events and system issues with their staff to promote awareness,
performance improvement and to improve safety.
9. Pharmacy automatically receives all medication events and will document their
evaluation and contributing factors, actions taken, etc. on the Pharmacy Manager page in
PSN.
E. Organizational Event Review Process
1. The event evaluation team meets regularly to review events with high harm scores along
with any case that was referred to the event evaluation team.
2. Each event evaluation team member has a defined role for which events they investigate
in preparation for the event evaluation team meeting.
3. Documentation of this review should be noted in the manager review screen by each
event evaluation team member reviewing the event.

Page 4 of 5

4. Risk Management, Quality, Safety & Innovation (QSI) and the event evaluation team
meeting notes will be documented in the Q/R review page in PSN.
5. Reported event information as well as the information found in the manager review and
Q/R review screens are discussed by the event evaluation team.
6. The event evaluation team determines when causal analysis is required and initiates the
causal analysis team. All causal analysis teams report their findings to a subcommittee of
the UW Health Safety Committee. In addition, the event evaluation team triages events
and may refer an event for further review/action to an applicable safety committee,
manager or to peer review.
7. The UW Health Safety Committee will be notified of all sentinel events and results of
causal analysis.
F. The UW Health Safety Committee
1. The UW Health Safety Committee communicates information about sentinel events and
results of causal analysis to leadership and the Board.
2. The UW Health Safety Committee evaluates event trends to determine appropriate
organizational responses to systems issues. Such initiatives may include chartering a
multidisciplinary improvement team to improve a specific process, provide education to
staff, etc.
G. Data Analysis
1. The event reporting database is administered and maintained by the Quality Safety and
Innovation (QSI) department.
2. QSI will provide periodic trended analysis reports to the UW Health Safety Committee
and/or the event evaluation team.
3. Data analysis will be performed by the appropriate safety committee(s) to determine
opportunities for improvement.
4. QSI can help managers and other relevant committees create reports from PSN on
specific patient safety events, aggregate trended data and information about follow up
that has occurred to address patient safety issues.
V. RESOURCES/REFERENCES
PSN Resource web page - U-Connect
Workers Compensation forms - U-Connect
Transplant Departmental Policy 3.19-Reporting Unexpected Events & Sentinel Event Status for
Transplant and Organ Procurement events

VI. COORDINATION
Senior Management Sponsor: UW Health VP, Quality, and Patient Safety
Author: Program Director, UW Health Program Director Organizational Performance & Patient Safety
Reviewer(s): Director, Risk Management, Medication Safety Officer, Nursing Quality Director, Legal
Services

Approval Committee(s): UW Health Patient Safety Committee, UW Health Administrative Policy
Committee
SIGNED BY
Elizabeth Bolt
UW Health Chief Administrative Officer

Revision Detail:

Page 5 of 5


Previous revision: 092013
Next revision: 112019