where do i report for patient safety issue

by Ms. Mina Smith PhD 3 min read

Report a Patient Safety Concern or File a Complaint

36 hours ago One Renaissance Boulevard. Oakbrook Terrace, Illinois 60181. By policy, The Joint Commission cannot accept copies of medical records, photos or billing invoices and other related personal information. These documents will be shredded upon receipt. Download the form for reporting a patient safety concern by mail. >> Go To The Portal


  • Online: Submit a new patient safety event or concern
  • Online: Submit an update to your incident (You must have your incident number)
  • Mail: Office of Quality and Patient Safety The Joint Commission One Renaissance Boulevard Oakbrook Terrace, Illinois 60181

File a Complaint Without Using Our Patient Safety Confidentiality Complaint Package
  • Mail or fax to the appropriate OCR regional office.
  • Email to OCRComplaint@hhs.gov.

How do I report patient safety concerns or compliance?

For urgent patient safety concerns, contact your supervisor. Use departmental chain of command for assistance. For compliance questions, please call 1-844-SPEAK2US (1-844-773-2528) Report event in HERO (Hopkins Event Reporting Online). For unresolved concerns, call the Safety Hotline at 410-955-5000.

How do you write a patient incident report?

In order to record the most accurate account of the incident, maintain an objective tone. Do not include assumptions or assign blame; just write down the facts. Where possible, include direct quotes from the patient and/or other involved parties. The higher your quality of writing, the more valuable your patient incident report will be.

How do I report safety concerns in the workplace?

To report any safety concerns, please use the following tips: For immediate hazards, call existing emergency phone numbers. For urgent patient safety concerns, contact your supervisor. Use departmental chain of command for assistance. Report event in HERO (Hopkins Event Reporting Online).

How do I report a hospital infection?

Clinicians are often legally required to report specific diseases, including some hospital infections, to their local (city) Department of Public Health which will accept the report, conduct an investigation, possibly complete laboratory testing and make recommendations to control an outbreak or improve patient safety.

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How do you report a patient event or a safety hazard in the environment?

Dial the Hotline (310) 825-9797 Follow the instructions by the voice operator and choose from the menu. A manager on call will respond based on the type of incident.

What organization is responsible for patient safety?

A Patient Safety Organization (PSO) works with healthcare providers to help them improve patient safety and healthcare quality and encourage a culture of safety.

What is patient safety report?

Patient Safety Reporting (PSR) gives military treatment facility personnel the ability to anonymously report medical events that impact the safety of patients.

How do you address a patient safety?

5 Patient-Centered Strategies to Improve Patient SafetyAllow patients access to EHR data, clinician notes. ... Care for hospital environment. ... Create a safe patient experience. ... Create simple and timely appointment scheduling. ... Encourage family and caregiver engagement.

What reports are encouraged as a result of the Patient Safety and Quality Improvement Act?

What reports are encourage as a result of the patient safety and quality improvement act? near misses, unsafe conditions, adverse events, events the threaten patient safety.

Which organizations deal with safety and health issues related to the healthcare industry?

U.S. Department of Health and Human Services (DHHS), National Institute for Occupational Safety and Health (NIOSH) Publication Number 2015-115, (October 2021). NIOSH/OSHA/CDC Toolkit.

What is the name of the system where incident reporting has to be done?

Incident Reporting Systems (IRS) are a cornerstone for improving patient safety.

What is incident reporting in healthcare?

Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care.

Which types of events should be reported in a safety report?

All team members are required to participate in the detection and reporting of any error, medication error, near miss, hazardous/unsafe condition, process failure, injuries involving patients, visitors and staff or a sentinel event.

What is the nurses role in patient safety?

From a patient safety perspective, a nurse's role includes monitoring patients for clinical deterioration, detecting errors and near misses, understanding care processes and weaknesses inherent in some systems, identifying and communicating changes in patient condition, and performing countless other tasks to ensure ...

What should a health care worker do immediately after a safety violation occurs?

What should a health care worker do immediately after a safety violation occurs? Report it to the supervisor.

What are some patient safety issues?

Patient safety issues and concernsMedication/drug errors. ... Healthcare-associated infections. ... Surgical errors and postoperative complications. ... Diagnostic errors. ... Laboratory/blood testing errors. ... Fall injuries. ... Communication errors. ... Patient identification errors.

About Patient Safety Confidentiality

OCR enforces the confidentiality provisions of the Patient Safety and Quality Improvement Act of 2005 (Patient Safety Act) and the Patient Safety and Quality Improvement Rule (Patient Safety Rule).

What is PSWP?

Assembled or developed by a health care provider for reporting to a Patient Safety Organization (PSO) that is listed by the HHS Agency for Healthcare Research and Quality (AHRQ) and is documented as being within the provider’s patient safety evaluation system for reporting to a PSO

Complaint Requirements

Anyone can file a patient safety confidentiality complaint. If you believe that a person or organization shared PSWP, you may file a complaint with OCR. Your complaint must:

File a Patient Safety Confidentiality Complaint

File a Complaint Using the Patient Safety Confidentiality Complaint Form Package

How OCR Investigates Your Complaint

OCR will investigate complaints that allege potential violations of the Rule. To the extent practicable, OCR will provide technical assistance and seek informal resolution of complaints involving the inappropriate sharing of PSWP through voluntary compliance from the responsible person, entity, or organization.

What is patient safety event reporting?

Patient safety event reporting systems are ubiquito us in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed information. Initial reports often come from the frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist, or physician caring for a patient when a medication error occurred), rather than management or patient safety professionals. Voluntary event reporting is therefore a passive form of surveillance for near misses or unsafe conditions, in contrast to more active methods of surveillance such as direct observation of providers or chart review using trigger tools. The Patient Safety Primer Detection of Safety Hazards provides a detailed discussion of other methods of identifying errors and latent safety problems.

How is event reporting used in health care?

A 2016 article contrasted event reporting in health care with event reporting in other high-risk industries (such as aviation), pointing out that event reporting systems in health care have placed too much emphasis on collecting reports instead of learning from the events that have been reported. Event reporting systems are best used as a way of identifying issues that require further, more detailed investigation. While event reporting utilization can be a marker of a positive safety culture within an organization, organizations should resist the temptation to encourage event reporting without a concrete plan for following up on reported events. A PSNet perspective described a framework for incorporating voluntary event reports into a cohesive plan for improving safety. The framework emphasizes analysis of the events and documenting process improvements arising from event analysis, rather than encouraging event reporting for its own sake.

What is the Patient Safety and Quality Improvement Act?

The legislation provides confidentiality and privilege protections for patient safety information when health care providers work with new expert entities known as Patient Safety Organizations (PSOs). Health care providers may choose to work with a PSO and specify the scope and volume of patient safety information to share with a PSO. Because health care providers can set limits on the ability of PSOs to use and share their information, this system does not follow the pattern of traditional voluntary reporting systems. However, health care providers and PSOs may aggregate patient safety event information on a voluntary basis, and AHRQ will establish a network of patient safety databases that can receive and aggregate nonidentifiable data that are submitted voluntarily. AHRQ has also developed Common Formats —standardized definitions and reporting formats for patient safety events—in order to facilitate aggregation of patient safety information. Since their initial release in 2009, the Common Formats have been updated and expanded to cover a broad range of safety events.

Why are event reports limited?

The spectrum of reported events is limited, in part due to the fact that physicians generally do not utilize voluntary event reporting systems.

Is there a voluntary event reporting system?

Voluntary event reporting systems need not be confined to a single hospital or organization. The United Kingdom's National Patient Safety Agency maintains the National Reporting and Learning System, a nationwide voluntary event reporting system, and the MEDMARX voluntary medication error reporting system in the U.S.

How long after incident should you report a patient?

Patient incident reports should be completed no more than 24 to 48 hours after the incident occurred. You may even want to file the report by the end of your shift to ensure you remember all the incident’s important details. RELATED: Near Miss Reporting: Why It’s Important.

What to include in an incident report?

Every facility has different needs, but your incident report form could include: 1 Date, time and location of the incident 2 Name and address of the facility where the incident occurred 3 Names of the patient and any other affected individuals 4 Names and roles of witnesses 5 Incident type and details, written in a chronological format 6 Details and total cost of injury and/or damage 7 Name of doctor who was notified 8 Suggestions for corrective action

Why is it important to review patient incidents?

Reviewing incidents helps administrators know what risk factors need to be corrected within their facilities , reducing the chance of similar incidents in the future.

Why is it important to know that an incident has occurred?

Knowing that an incident has occurred can push administrators to correct factors that contributed to the incident. This reduces the risk of similar incidents in the future. Quality control. Medical facilities want to provide the best care and customer service possible.

Why do we use resolved patient incident reports?

Using resolved patient incident reports to train new staff helps prepare them for real situations that could occur in the facility. Similarly, current staff can review old reports to learn from their own or others’ mistakes and keep more incidents from occurring. Legal evidence.

How long does it take to file a patient incident report?

Patient incident reports should be completed no more than 24 to 48 hours after the incident occurred.

Why is it important to document an incident?

Even if an incident seems minor or didn’t result in any harm, it is still important to document it. Whether a patient has an allergic reaction to a medication or a visitor trips over an electrical cord, these incidents provide insight into how your facility can provide a better, safer environment.

What is patient safety?

Patient Safety is a health care discipline that emerged with the evolving complexity in health care systems and the resulting rise of patient harm in health care facilities. It aims to prevent and reduce risks, errors and harm that occur to patients during provision of health care.

Why is patient safety important?

Patient safety is fundamental to delivering quality essential health services. Indeed, there is a clear consensus that quality health services across the world should be effective, safe and people-centred. In addition, to realize the benefits of quality health care, health services must be timely, equitable, integrated and efficient.

What is the WHO patient safety and risk management unit?

The Patient Safety and Risk Management unit at WHO has been instrumental in advancing and shaping the patient safety agenda globally by focusing on driving improvements in some key strategic areas through:

When did WHO start working on patient safety?

WHO's work on patient safety began with the launch of the World Alliance for Patient Safety in 2004 and this work has continued to evolve over time. WHO has facilitated improvements in the safety of health care within Member States through establishment of Global Patient Safety Challenges.

When is World Patient Safety Day?

Recognizing that Patient Safety is a global health priority, the World Health Assembly (WHA) adopted a resolution on Patient Safety which endorsed the establishment of World Patient Safety Day to be observed annually by Member States on 17 September.

What are some examples of quality of care complaints?

Some common examples of quality of care complaints include: Receiving the wrong medication in a hospital or skilled nursing facility (SNF) Receiving unnecessary surgery/diagnostic testing. Receiving an overdose of medication. Experiencing a delay in service. Receiving inadequate care or treatment by a Medicare hospital or doctor.

What is the role of the state health department?

State Health Departments. Each state has a Department of Public Health that works to ensure the health and safety of its residents. Clinicians are often legally required to report specific diseases, including some hospital infections, to their local (city) Department of Public Health which will accept the report, conduct an investigation, ...

Does Medicare have a complaint right?

Every Medicare beneficiary has the right to file a complaint, or to register a concern about their health care or health care provider. Patients and their advocates should realize that they have this right and know how to reach the entity that can take action on their complaints.

Why is patient monitoring important in nursing?

Patient Safety Issues in Nursing. Patient monitoring also suffers (mostly due to nurse case overload) – negatively impacting patient safety. Improved patient monitoring can help to detect problems that arise during treatment within the care unit, and enforce rehabilitation measures before a condition worsens.

Why is it important to wash hands before and after patient contact?

Washing hands before and after patient contact is one of the basic infection control measures hospitals can enforce as a policy. Hand washing can stop the spread of bacteria, especially when all parties are diligent.

How to prevent sick staff from coming to work?

Enforce a strict policy that prevents sick staff members from coming to work. Open additional telehealth appointments, so that patients have the option to see doctors from the safety of their home and minimize potential exposure. Ensure that any patient that enters the facility is pre-screened or tested for COVID-19.

What is the need for discussion and priority setting both at the provider and the national level?

There is a need for discussions and priority setting both at the provider and the national level to design and dictate safety efforts and policies. In fact, a few states have established new legislation regarding hospital staffing to address nurse/physician burnout, but much more needs to be done.

What percentage of physicians show burnout?

43.9% of U.S. physicians showed signs of burnout in 2017, according to a study by AMA and Mayo Clinic. The primary source of burnout stems from the extensive data entry and related clerical work that physicians cover on a daily basis.

Who can address complaints about health care safety?

Anyone from a city councilman to a U.S. representative can address complaints about health care safety. Professional nurses associations. Although the ANA can't intercede on an individual nurse's behalf, Grant says, it can advise nurses on possible options for recourse. Nursing union.

Who evaluates nursing reports?

State boards of nursing, which are in charge of nursing licensure, evaluate reports about nurses who may be unsafe. An attorney. Speaking to a nurse attorney or another attorney when considering reporting or in the aftermath of a safety issue can help nurses protect themselves. The public.

What are the problems with RNs?

Nurse practitioners and staff RNs report a variety of problems within health care facilities. Frequently reported issues include the following: 1 Inadequate staffing levels. 2 Lack of personal protective equipment and PPE violations. 3 Unsafe, unsanitary work environments. 4 Violence in areas such as emergency rooms and psychiatric units. 5 Colleagues whose unsafe practices endanger patients.

How can the nurse's problem be addressed?

The nurse's problem can now be addressed through treatment and confidential monitoring programs – and patients are no longer endangered. "It's important to say that 99% of nurses are extremely safe and very competent practitioners," Alexander emphasizes.

Can you report a fellow nurse?

It's hard to report on a fellow staff nurse or nurse employee but sometimes there's no other choice. State boards of nursing receive reports about nurses who may be unsafe.

Do nurses have to report retribution?

Nurse practitioners and registered nurses who have issues to report may be understandably concerned about the fear of retribution and being let go, Thomas says. Even if nurses haven't experienced retribution firsthand, she says, they're seeing examples of that happening in media coverage.

Is oral reporting bad for nurses?

But nurses can object to issues concerning staffing or anything else in writing where the patient or nurse is in jeopardy in terms of their respective safety.".

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Background

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Patient safety event reporting systems are ubiquitous in hospitals and are a mainstay of efforts to detect patient safety events and quality problems. Incident reporting is frequently used as a general term for all voluntary patient safety event reporting systems, which rely on those involved in events to provide detailed infor…
See more on psnet.ahrq.gov

Characteristics of Incident Reporting Systems

  • An effective event reporting system should have four key attributes: While traditional event reporting systems have been paper based, technological enhancements have allowed the development of Web-based systems and systems that can receive information from electronic medical records. Specialized systems have also been developed for specific settings, such as th…
See more on psnet.ahrq.gov

Limitations of Event Reporting

  • The limitations of voluntary event reporting systems have been well documented. Event reports are subject to selection bias due to their voluntary nature. Compared with medical record review and direct observation, event reports capture only a fraction of events and may not reliably identify serious events. The spectrum of reported events is limited, in part due to the fact that ph…
See more on psnet.ahrq.gov

Using Event Reports to Improve Safety

  • A 2016 article contrasted event reporting in health care with event reporting in other high-risk industries (such as aviation), pointing out that event reporting systems in health care have placed too much emphasis on collecting reports instead of learning from the events that have been reported. Event reporting systems are best used as a way of identifying issues that require furth…
See more on psnet.ahrq.gov

Current Context

  • At the national level, regulations implementing the Patient Safety and Quality Improvement Act became effective on January 19, 2009. The legislation provides confidentiality and privilege protections for patient safety information when health care providers work with new expert entities known as Patient Safety Organizations (PSOs). Health care providers may choose to wo…
See more on psnet.ahrq.gov