UC Davis Health System

Transcription

1 UC Davis Health System Application Programming & Project Management I NSTRUCTION M ANUAL Incident Reporting 2.0 Reporter Guide August 2, 2004 Developed by Michael I. Jacobs Programmer Scott P. Silva Project Development Analyst Information & Communication Services

2 Table of Contents Revision Information...2 Overview...2 Definition of Roles...3 IR 2.0 Home Page...4 Create Profile/ Edit Profile...5 Logging Into the System...7 Entering a New Incident...9 Start Page...10 Step 1 General Questions...11 Step 2 Category Selection...15 Step 3 Subcategory Questions...17 Step 4 Incident Detail...18 Step 5 Witnesses...19 Step 6 Incident Summary...22 Confirmation Box...23 Incident Complete Page...24 Relating an Incident...24 Saving a New Incident...25 Editing an Incident...26 What Happens Next With an Incident...26 Help...27 Main Menu...27 Logoff...28 Time Out Warning...28 REVISION INFORMATION Rev. # Date Summary of Changes Author 1 03/12/03 New Scott P. Silva 2 08/02/04 Revision Scott P. Silva OVERVIEW In 1998, the Institute of Medicine released a report, To Err is Human, that found that 44,000 to 98,000 deaths occur nationally ever year as a result of medical errors and adverse events at a cost of $37.6 billion annually. Tragically, over two-thirds of medical errors are preventable; unfortunately between 50% and 96% of them are never reported, leaving hospitals at risk of making the same mistakes again. The Incident Reporting (IR 2.0) system was created to help hospitals learn from adverse events and medical errors to prevent future problems from occurring. It is also designed to give notice 2

3 to the appropriate personnel immediately and efficiently to deal with current events. IR 2.0 is a Web-based tool that allows Reporters to rapidly enter Incident information and quickly return to patient care, but gives Administrators, Supervisors and Managers the data they need to track Incident trends and improve hospital practices. Incident Reporting 2.0 represents a tremendous advance for the University of California system. It is an application that has been developed by UC Davis, in a collaborative process with all UC Medical Centers. Using state-of-the-art programming, it dramatically increases functionality in this breaking area of medical research and health-care policy. DEFINITION OF ROLES In IR 2.0, there are three major roles: Reporter, Manager and Administrator. Reporters are the people who initially enter Incidents. They answer the initial questions and provide the details of the Incident. After they complete an Incident report, it is stored in the system and specific Managers receive a notification about the report s existence. Managers are the primary reviewers of Incidents and perform most of the follow-up into an Incident, from further investigation, to examination of trends, and potential referral to other appropriate staff. Managers can be involved in an Incident based on several different criteria, such as Category, Subcategory, Department, Division, Location, Unit, Severity, and more. Administrators serve two roles in the system. They review Incidents of particular importance and they maintain and operate the overall system. With their system-wide scope, they also utilize much of the system s reporting capabilities to analyze and report trends. 3

4 IR 2.0 HOME PAGE The IR 2.0 application is accessed via a web browser. Whether you enter the system s URL address or its alias, or you link to the site from another web page, the IR 2.0 Home Page will appear. To enter the system, you will be required to enter your userid and password. If you do not have a userid and password, you will have to create a profile as explained in the next section. 4

5 CREATE PROFILE/ EDIT PROFILE If you do not have a profile created, first click on the Create Profile link on the Home Page. Once on the Create Profile page, fill in the demographic information requested in each field (required fields are marked with an asterisk). Any userid and password can be selected as long as they meet the minimum length (5 characters for userid and password). The system will prevent you from choosing a userid that is in use by someone else. (Note that once you have selected a userid, it cannot be changed.) 5

6 Once all necessary information is entered, click on the Save Profile button and the browser will return to the Home Page, which will now display additional options: New Incident, Edit Incident and Edit Profile (which replaces Create Profile). If Edit Profile is clicked, the browser will go to the Profile page, which is now pre-populated with your previously entered data. You can make any desired changes, then save them by clicking on Save Profile. (Note that a userid cannot be changed.) 6

7 LOGGING INTO THE SYSTEM If a user profile has already been created, enter the userid and password at this point. 7

8 Once successfully logged into the system, several more options will appear: New Incident, Edit Incident and Edit Profile (replacing Create Profile). 8

9 ENTERING A NEW INCIDENT After logging in, click on the New Incident link to begin the Incident creation process. 9

10 Start Page The system will then display the Start page, which contains basic legal information and instructions on entering an Incident. It also describes what is and what is not covered by the system, and provides a link to more information about non-covered occurrences. To begin Incident entry, click on the Enter New Incident button. 10

11 Note: The system will always display your progress in the Incident entry process by highlighting the current step at the top of the browser and the current page within a step on the upper right. Step 1 General Questions In Step 1, general information about the event is collected. On the first page in this step, choose what type of Incident occurred, if it involved a patient, visitor, employee, or none of them. If a patient was involved, also enter the Medical Record Number (MRN) in the field provided. To continue to enter the Incident, click on the Next button. Throughout the entry process, you can proceed to the next screen by hitting this button, or return to the previous screen by clicking on the Back button (Note: the arrows on the browser itself should not be used). By clicking on the Reset button, you can also restore a page to the condition it was when the browser entered it. 11

12 The next page contains demographic information about the Incident, varying depending on the Incident type previously selected. All types will require the Date and Time. The Patient page will also require the First Name, Middle Initial, Last Name, Date of Birth and Gender. (Note: If a site has automatic MRN validation, these fields will be pre-populated). The Visitor page will require the First Name, Middle Initial and Last Name. The Employee page will require the First Name, Middle Initial, Last Name, and Role. The Non-Person page will not require any additional information. Enter the information requested and click the Next button to proceed. 12

13 The third page will ask which Clinical Department and Division was involved in the Incident (Patient Incidents only) and the Location and the Unit where the Incident occurred. 13

14 The last page in this step will ask general questions (i.e. ones that apply to all Incidents). 14

15 Step 2 Category Selection The first page in this step asks for the Category of the Incident (e.g. Anesthesia Issues, Medication Related Events). To make this selection, click on the appropriate Category name or on the diamond symbol to the left of it. Before you make a selection, if you wish to know the Subcategories within a Category, move the mouse cursor over its name to have a pop-up box display them. If you navigate back to this page, and you select a different Category, the system will display a warning pop-up box that will ask you to confirm that you wish to change the Category. 15

16 The second, and last, page in this step asks for further specification about the Incident. It asks you to select a Subcategory within the overall Category. Just as in the Category selection, click on the diamond symbol by the appropriate Subcategory name. A Category may have only one Subcategory or it may have several. 16

17 Step 3 Subcategory Questions This step contains questions specific to the Subcategory chosen in Step 2. If a Subcategory does not have any specific questions, this step will be skipped. You may need to answer only a few questions, or you may need to answer a more substantial number, depending on the Subcategory. Questions in boldface are required and must be answered before leaving each page. 17

18 Step 4 Incident Detail This step asks for a general description of the Incident and all relevant information in a free-text field. The field has a limit of 5000 characters (which is equivalent to approximately four doublespaced pages). 18

19 Step 5 Witnesses This step collects information on witnesses, if any. 19

20 To add a witness, click on the Add button to go to the witness information page. Enter all known information about the witness, including First Name, Middle Initial, Last Name, Title, Phone Number, whether the witness is, or isn t, an employee, and any general notes. To save the entered data, click the Add button; to cancel the information entered, click the Cancel button. Either way, the browser will return to the Witnesses page, with a list of all witnesses displayed. 20

21 If you decide that you want to delete a witness from the list, check the box beside the name, then click the delete button. A pop-up box will appear and ask you to confirm deletion of the witness entry; click the OK button to do so. When all witnesses are entered, click the Next button. 21

22 Step 6 Incident Summary This step does not require any additional information be entered, but is a summary page for you to review what has been answered and ensure its accuracy. If you have missed any required information (due to skipping ahead), it will be highlighted in red. If a change is needed, you can click the Back button on the page (repeatedly if necessary), use the step map at the top of the page to link directly to the step in question, or click on the step name in the summary itself to link directly to the step. If either linking option is chosen, the browser will go to the first page in that step; you can then navigate to a later page using the Next button. Once the changes have been made, the Next button should be clicked to save them. To return to Step 6, use the Next button, the Save and Finish button, or the step map at the top of the page. 22

23 Once the information is correct, click the Submit button to complete the Incident. Confirmation Box This pop-up box asks you to confirm your submission of the Incident. 23

24 Incident Complete Page This page informs you that the Incident has been completed. To enter another Incident, click on the Enter a New Incident button; to create an Incident that is related to the just-entered Incident, click on the Enter Related Incident button. You can also return to the Main Menu by clicking on the Main Menu button, or log out of the system completely by clicking on the Close Window button. RELATING AN INCIDENT If you believe that two (or more) Incidents are related, you can choose the Enter Related Incident button. Once the button is clicked, you will be taken to the beginning of the Incident Entry process. Certain data that should be consistent between the Incidents will be pre-populated, though if necessary, you have the option of changing it. At this point, enter the Related Incident by going through the Incident creation process again. After this Incident is created and submitted, you will have the same four choices, and could potentially relate another Incident, or Incidents, to the first two. [Note: All related Incidents will be related into one group as a whole. Incidents cannot be related to just some of the Incidents in the group. If Incident A is related to Incident B, and Incident C is related to Incident B, then C is also related to A.] 24

25 SAVING A NEW INCIDENT If it is not possible to finish an Incident at a given time, you can click the Save Incident link, which will allow the completion of the report at another time. Note that only the original Reporter can finish the report; if you do not go back to it, the information will never be routed to anyone else. (Note: Some sites do not allow the saving of Incidents.) 25

26 EDITING AN INCIDENT When an Incident has been previously saved, it can be finished by clicking on the Edit Incident link on the Main Menu. The application will take the browser back to the beginning of the previously saved Incident, but with all of the previously entered data in its respective fields. To finish, simply enter the remaining data and complete the Incident like any other. WHAT HAPPENS NEXT WITH AN INCIDENT After an Incident is successfully completed, an will be sent to the reviewers designated by the Site s Administrators. The reviewers in question may be designated based on the Category or Subcategory, the Location or Unit, the clinical Department or Division, or the severity of the Incident. The reviewer may electronically send it to other staff to examine, or have additional questions to ask the original Reporter. 26

27 HELP At any point in the Incident entry process, you can click on this link to receive more information on the system. MAIN MENU If this link is clicked during the Incident entry process, the application will display a warning box that says that if you go back to the Main Menu, all entered information will be lost. If you then click OK, you will be returned to the Incident in progress; to cancel the Incident, click the Cancel button to return to the Main Menu. 27

28 LOGOFF If this link is clicked during the Incident entry process, the application will display a warning box that says that if you log out, all entered information will be lost. If you then click OK, you will be returned to the Incident in progress; to cancel the Incident, click the Cancel button to log out of the system. TIME OUT WARNING If too much time elapses on one page of the Incident Entry process, you will see a warning box pop up informing you of how much time you have left on that page. If you proceed to another page, the system s timer will be reset. If time is running short, you may want to click the Next button to proceed to the next page, then click the Back button and continue. Additionally, you can also Save the Incident, then reopen it. 28