Biovigilance Component Hemovigilance Module Incident Reporting

1y ago
33 Views
2 Downloads
1.60 MB
39 Pages
Last View : Today
Last Download : 2m ago
Upload by : Fiona Harless
Transcription

Biovigilance ComponentHemovigilance ModuleIncident ReportingNational Center for Emerging and Zoonotic Infectious DiseasesDivision of Healthcare Quality Promotion1

Objectives Review key terms used in incident reporting.Provide instructions for incident reporting. Required reporting Optional reporting Review case studies for Incident reporting in theHemovigilance Module.2

Hemovigilance Module Incident Formand Table of Instructions3

Key Terms in Incident ReportingIncident – Any error or accident that could affect thequality or efficacy of blood, blood components, or patienttransfusions. It may or may not result in an adversereaction in a transfusion recipient.Near Miss – A subset of incidents that are discoveredbefore the start of a transfusion that could have led to awrongful transfusion or an adverse reaction in atransfusion recipient.4

Key Terms in Incident Reporting (cont.)Incident Results Product transfused, reactionA product related to this incident was transfused; the patient experienced anadverse reaction Product transfused, no reactionA product related to this incident was transfused; the patient did notexperience an adverse reaction No product transfused, unplanned recoveryNo product was transfused; the incident was discovered ad hoc, by accident,by a human lucky catch, etc. No product transfused, planned recoveryNo product was transfused; the incident was discovered through astandardized process or barrier designed to prevent errors5

Incident CodesThere are 100 Incidents defined in the HemovigilanceModule.6

Process CodesTransfusion Services PC Product Check-in Products received from outside source Returned to inventory from patient care area SR Sample Receipt Receipt of sample in transfusion servicesST Sample Testing Testing of sample, type & crossmatchUS Product Storage Storage of blood and blood products inTransfusion Services AV Available for Issue Quality management of product inventorySE Product Selection When products are selected fortransfusionUM Product Manipulation When pooling, irradiating, dividing,thawing, and labeling productsUI Product Issue Issue of blood products from TransfusionServicesMS OtherClinical ServicesPR Product/Test Request Request of a test or product by clinicalservice (online or requisition)SC Sample Collection Service collecting the samplesSH Sample Handling Paperwork accompanying the sample fortestingRP Request for Pick-up Product requestUT Product Administration Product transfusedMS Other7

Before Entering Event Forms Be sure that your facility has completed: Annual Facility Survey Monthly Reporting Plan(s)8

Hemovigilance Module IncidentsRequired Reporting All incidents (i.e., accidents or errors) that are associatedwith a reported adverse reaction must be reported using adetailed Incident form. If multiple incidents occur in association with an adversereaction, report all of them on separate Incident forms. Classify incidents using Incident Codes in Section 4 of theprotocol. Detailed instructions on how to complete the form areprovided on the Website.9

Hemovigilance Module IncidentsRequired ReportingEnterMonthlyReportingPlanPR01Enter Incident forms for allincidents associated withan adverse reactionUT07ST10Enter MonthlyReportingDenominatorsform10

Hemovigilance Module IncidentsRequired ReportingFrom the home page, select “Incident“ from the left-handnavigation bar and click “Add.”11

Hemovigilance Module IncidentsRequired Reporting Date and time of discovery Enter the date and time the incident was first noticed by staff. Where in the facility was the incident discovered? Select a facility-defined NHSN location. This may or may not be the same location where the incidentoccurred.12

Hemovigilance Module IncidentsRequired Reporting How was the incident first discovered? Select the description that most closely describes how theincident was initially discovered by staff. If “Other” is selected, include a brief description in the spaceprovided. At what point in the process was the incident firstdiscovered? Use the Process Codes in Section 4 of the protocol.13

Hemovigilance Module IncidentsRequired Reporting Date and time the incident occurred Enter the date and time the incident first happened. Where in the facility did the incident occur? Select the facility-defined NHSN location. Job function of the worker involved in the incident(optional): Use the CDC occupation codes in Section 4 of the protocol.14

Hemovigilance Module IncidentsRequired Reporting At what point in the process did the incident firstoccur? Select the process point at which the incident began. Incident code See Section 4 of the protocol for a list of incident codes. Incident summary (optional) Enter a brief, descriptive explanation of exactly what happened.15

Hemovigilance Module IncidentsRequired Reporting Incident Results Select “Product transfused; reaction” for incidents associated withan adverse reaction. “Product action” and “Was a patient reaction associated with thisincident?” will be auto-completed.16

Hemovigilance Module IncidentsRequired Reporting Enter the Patient ID of the patient that experienced theadverse reaction associated with the incident.After the incident record is entered, the adverse reactionrecord must be linked to the incident record. The Patient ID on both forms must match in order to link therecords.17

Hemovigilance Module IncidentsRequired Reporting Root Cause Analysis A facility may choose to conduct a formal administrativeinvestigation aimed at identifying the problems or causes of anincident. If a root cause analysis is performed, check all results that apply.Detailed definitions of root cause analysis results can be found inSection 4 of the protocol.18

Don’t forget to SAVE! Remember to SAVE before leaving the page. Forms cannot be left unfinished and completed later. Forms cannot be saved unless all required fields are entered.19

Topics Covered So Far Key terms in incident reporting in NHSNRequired Incidents reportingComing Up Next Optional Incident reportingIncident case studies20

Hemovigilance Module IncidentsOptional Reporting Incidents reported optionally are for facility use onlyand will not be analyzed by CDC. Facilities that wish to conduct comprehensive incidentsurveillance can choose from the following reportingmethods:1.2.3.Detailed reporting using Incident formsSummary reporting using Monthly Incident Summary formCombination of detailed and summary reporting21

Optional Comprehensive Incident SurveillanceDetailed ReportingAny incident NOT associated with an adverse reaction canbe optionally reported using a detailed Incident form.22

Optional Comprehensive Incident SurveillanceSummary Reporting Monthly Incident Summary forms should be completedfor optional summary incidents where only the totalnumber of incidents is reported. Optional summary reporting should also includerequired incident data. 4 required incidents 6 optional incidents 10 total incidentsreported on Monthly Incident Summary form Continue reporting incidents associated with anadverse reaction using Incident forms.23

Hemovigilance Module Monthly IncidentSummary Form and Tables of Instructions24

Hemovigilance Module IncidentsOptional Summary ReportingEnter MonthlyReporting PlanTrack incident datathroughout the monthEnter MonthlyIncidentSummaryEnter MonthlyDenominators25

Hemovigilance Module IncidentsOptional Summary ReportingComplete a Monthly Incident Summary form for allincidents that occur throughout the reporting month.26

Hemovigilance Module IncidentsOptional Summary Reporting Select “Summary Data”Click “Add”Select “Monthly Incident Summary” from the dropdown menuClick “Continue”27

Hemovigilance Module IncidentsOptional Summary ReportingSelect the Month and Year from the drop-down menus.28

Hemovigilance Module IncidentsOptional Summary Reporting Process and Incident code Use Section 4 in the protocol to help select the appropriatecode(s). Add additional rows as needed. Total Incidents and Adverse Reactions associated withIncidents Enter ‘0’ (zero) if no adverse reactions were associated with theincident.29

INCIDENT REPORTINGCASE STUDIES30

Case Study #1At 08:30 a.m. on 3/20/2012, the blood bank discovered that awrong unit may have been issued to patient B. Thomas. Thetechnologist called the ICU and asked the nurse to check theidentification of two units that had been issued for patient B.Thomas . One of the bags issued had the name and hospitalnumber of another patient with the same last name. Thepatient had already received the incorrect unit starting at 04:55a.m. that day.The attending physician and hematologist were notifiedimmediately. At 8:45 a.m. the patient began to experiencedyspnea, chest pain, nausea, and developed acute kidney failurewith an urine output of 40 mL/hr and a rise in creatinine, LDH,potassium, and bilirubin. The hemoglobin dropped from 10.7 to8.3.The patient did not require dialysis, and urine output was normalby the next day. In the days that followed, hydration wasmaintained at 80 mL/hr and the patient’s renal functioncontinued to improve. She was discharged on 3/25/2012.31

Case Study #1Facilities must choose detailed reporting of all incidents onthe Monthly Reporting Plan and complete a detailedIncident form for all incidents associated with an adversereactions.32

Case Study #133

Case Study #1This is the same Patient ID #that must be used whencompleting an AdverseReaction form in NHSN.34

Case Study #1Remember to SAVE the record before navigating away fromany form in NHSN.35

Case Study #2Optional Incident ReportingDuring March 2012, a hospital decided to collectcomprehensive incident summary data using the MonthlyIncident Summary form. During the month, the hospitalrecorded 12 incidents, including one incident that wasassociated with an adverse reaction.3 units of RBCs were shipped inappropriately, 1patient wascollected by mistake, 7 samples had labels that were eitherillegible, incorrect, or incomplete. One patient received thewrong product that led to an adverse reaction.36

Case Study #2Optional Incident ReportingFacilities must choose detailed reporting of all incidents onthe Monthly Reporting Plan but may enter optionalsummary data using the Monthly Incident Summary form.37

Case Study #2Optional Incident Reporting38

Questions or Need Help?Contact User Supportnhsn@cdc.gov39

Key terms in incident reporting in NHSN Required Incidents reporting . Coming Up Next Optional Incident reporting Incident case studies . 20 . So far, the key terms in incident reporting and required Incidents reporting have been covered. Next, optional Incidents repor\൴ing as well as incident case studies will be discussed.

Related Documents:

Summary reporting of in\ൣidents requires facilities to complete the Hemovigilance Module Monthly Incident Summary form with all incidents that occurred.對 However, regardless of the method chosen to report incidents, detailed incident forms are required for all high-priority incid\ nts and incidents that are related to an adverse reaction.

Teacher’s Book B LEVEL - English in school 6 Contents Prologue 8 Test paper answers 10 Practice Test 1 11 Module 1 11 Module 2 12 Module 3 15 Practice Test 2 16 Module 1 16 Module 2 17 Module 3 20 Practice Test 3 21 Module 1 21 Module 2 22 Module 3 25 Practice Test 4 26 Module 1 26 Module 2 27 Module 3 30 Practice Test 5 31 Module 1 31 Module .

Incident Management Process Map 1. Incident Management Process Map 1. Incident Management Description and Goals 9. Incident Management Description and Goals 9. Description 9. Description 9. Goals 9. Goals 9. Incident Management RACI Information 10. Incident Management RACI Information 10. Incident Management Associated Artifacts Information 24

WinDbg Commands . 0:000 k . Module!FunctionD Module!FunctionC 130 Module!FunctionB 220 Module!FunctionA 110 . User Stack for TID 102. Module!FunctionA Module!FunctionB Module!FunctionC Saves return address Module!FunctionA 110 Saves return address Module!FunctionB 220 Module!FunctionD Saves return address Module!FunctionC 130 Resumes from address

XBEE PRO S2C Wire XBEE Base Board (AADD) XBEE PRO S2C U.FL XBEE Pro S1 Wire RF & TRANSRECEIVER MODULE XBEE MODULE 2. SIM800A/800 Module SIM800C Module SIM868 Module SIM808 Module SIM7600EI MODULE SIM7600CE-L Module SIM7600I Module SIM800L With ESP32 Wrover B M590 MODULE GSM Card SIM800A LM2576

RR Donnelley Component R.R. Donnelley Printing Companies Component Haddon Component Banta Employees Component Banta Book Group Component Banta Danbury Component Banta Specialty Converting Component Moore Wallace Component (other than Cardinal Brands Benefit and Check Printers Benefit) Cardinal Brands Benefit of the Moore Wallace Component

TIBRS Incident Report ORI # Incident # CAD # Incident Date Incident Time Incident Date is: Address # Street Name Apt./Suite # City State Zip Code Zone Latitude Longitude Arrival Date Arrival Time Officer Cleared by: Exceptional Clearance Ex. Clearance Date Offense # 1 T.C.A. Offense TIBRS Offens

in Acute Mental Health Care was launched in the Houses of Parliament. A joint production with The Princess Royal Trust for Carers and the National Mental Health Development; the guide received a positive reception from professionals, carers and service users alike. Carers Trust is a new charity formed by the merger of The Princess Royal Trust for Carers and Crossroads Care. Carers Trust now .