D.21- REPORTING PATIENT SAFETY INCIDENTS IN THE JOINT PATIENT SAFETY REPORTING SYSTEM-JPSR.pdf
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- Solicitation number
- 36C24224R0049
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This document is a Standard Operating Procedure (SOP) that establishes procedures for using the Joint Patient Safety Reporting System (JPSR) to report incidents, close calls, and adverse events at the Syracuse VA Medical Center and its Community-Based Outpatient Clinics (CBOCs). The SOP outlines the types of events that must be reported in JPSR, the process for reporting incidents, the responsibilities of the Patient Safety Manager and other staff, and the procedures for handling JPSR system outages. The document also provides links to relevant VA publications and resources related to JPSR.
The related federal contract opportunity is a Request for Proposal (RFP) for Community Based Outpatient Clinic (CBOC) services to provide primary care services to Veteran patients in Cayuga County, New York. The contract will cover a base year and nine one-year option periods. The NAICS code for this requirement is 621498 All other Outpatient Care Centers, with a $25.5 Million size standard. The RFP is an unrestricted procurement with a single award contract.
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REPORTING PATIENT SAFETY INCIDENTS IN THE JOINT PATIENT SAFETY
REPORTING SYSTEM (JPSR)
SOP 00PS-001
Syracuse VA Medical Center Syracuse, NY 13210
Signatory Authority:
Quality Manager
Responsible Owner:
Patient Safety Manager
Service Line(s):
Quality Management
Effective Date:
September 2021
Recertification Date:
September 2026
1. PURPOSE AND AUTHORITY
a. The purpose of this standard operating procedure (SOP) is to establish procedures on using the Joint Patient Safety Reporting System (JPSR) to report incidents, close calls, and adverse events. This SOP must be followed by all Syracuse VA Medical Center and Community-Based Outpatient Clinic (CBOC) staff.
b. There is no governing document.
2. PROCEDURES
a. Requirements for reporting.
(1) All staff will have the option to report anonymously via JPSR.
(2) Types of events to report in JPSR (list is not all-inclusive):
(a) Potential event (unsafe condition).
(b) Near miss.
(c) Adverse event (causing harm).
(d) Sentinel event.
(e) Equipment/supply related event.
(f) Falls.
(g) Medication errors.
(h) Missing patient events.
(i) Non-VA Care incidents.
Attachment D.21 RFP 36C24224R0049
September 2021 SOP 00PS-001
(j) Pressure ulcer events.
(k) Suicide attempts or completions.
(l) Fire with oxygen use.
(m) Radiation overexposure.
(n) Transfusion errors, blood or blood product administration errors.
(o) Mislabeled specimen incidents.
(p) Communication failures or delays in care.
(q) Failure to obtain informed consent.
(r) Wrong counts following surgical procedures.
(s) Surgery misadventures.
(3) JPSR is not used to report deliberate unsafe acts, employee safety events, or patient family member/visitor events. These are reported through Reports of Contact (ROC), Employees’ Compensation Operations and Management Portal (ECOMP), and/or Police reports.
b. Reporting an incident, adverse event or close call.
(1) When an adverse event or close call occurs:
(a) The employee will notify a supervisor or provider to ensure the patient is examined.
(b) If equipment is involved, take steps to ensure the equipment is taken out of service.
(c) Preserve all medication packaging, medical device packaging, or any other evidence involved in the incident.
c. Entering a report into JPSR.
(a) Navigate to the JPSR link via the Syracuse VA Intranet page under “Frequently Used Log Ins”.
(b) Using a Personal Identity Verification (PIV) card (required to log in), access the reporting form.
(c) Utilize ‘Department of Veterans Affairs’ once logged in.
(d) Fill out all mandatory fields as marked with an asterisk (*).
(e) Be as descriptive and thorough as possible when describing the event.
(f) Manually type the Veteran’s last four numbers of the Social Security Number (SSN) under the Date of Birth; there is no dedicated field for the SSN.
1. Reports will be maintained electronically; no paper copies will be printed or maintained. Electronic records are protected by 38 USC 5705 and are considered sensitive, confidential and privileged.
d. After report is submitted.
(1) Once a JPSR report is received, the facility will have seven business days to investigate the event, and twelve business days to close out the event in JPSR.
(2) Contingency plan.
(a) In the event JPSR is down, paper contingency forms are available for staff to report incidents (see Appendix A).
(b) Completed paper contingency forms will be sent via interoffice mail to the Patient Safety Manager.
3. ASSIGNMENT OF RESPONSIBILITIES
a. Patient Safety Manager. The Patient Safety Manager is responsible for:
(1) Receiving and reviewing electronic and paper copies of JPSR reports.
(2) Educating, promoting, tracking, trending and analyzing adverse events and close call reporting.
(3) Scoring each reported event using a Safety Assessment Code (SAC) score and collaborating with facility leadership to determine the need for a Root Cause Analysis (RCA), fact-finding, or administrative investigation.
(4) Notifying local leadership of an adverse event or close call of a serious nature.
(5) Providing “Just in Time” training to staff and participating as an advisor to the team.
(6) Inputting completed RCAs into ‘Web SPOT’ (the Patient Safety information tool) and sending electronically to the National Center for Patient Safety.
(7) Facilitating the Healthcare Failure Mode Effect and Analysis Process (HFMEA) as needed.
(8) Assigning a reviewer in JPSR to investigate the event, taking into consideration the type and location of event.
(9) Reporting adverse events or close calls to Local Leadership Council, Medical Staff Executive Committee, Local Pharmacy and Therapeutics Committee, Environment of Care Committee and Nurse Professional Council. These reports are given monthly and quarterly, with an annual summary report.
b. Nurse Manager/Supervisor. The Nurse Manager/Supervisor is responsible for:
(1) Ensuring incident reports are appropriately documented in CPRS by nursing staff and forwarding to the Patient Safety Manager.
(2) Assisting the Patient Safety Manager with actively investigating incident reports when they are assigned in JPSR.
c. Syracuse VA Medical Center (SVAMC) Staff. SVAMC staff are all responsible for:
(1) Individual work practices which promote a safe, therapeutic environment.
(2) Encouraging reporting of all witnessed and discovered incidents or close calls in an effort to improve systems and process design.
(3) Reporting events in JPSR as soon as possible after discovery. A Report of Contact form may also be used; however, these reports are not received by the Patient Safety Manager.
(4) Reporting serious adverse events or close calls to the Patient Safety Manager, Risk Manager, or Patient Safety/Risk Management Specialist immediately after discovery of the incident. Off-tour events may be reported to the off-tour supervisor.
4. DEFINITIONS
a. Joint Patient Safety Reporting System (JPSR). JPSR is a commercial web-based platform maintained by a third-party administrator in collaboration with the Department of Defense (DoD). JPSR is where staff will report incidents, close calls, and adverse events. The intent of JPSR is to standardize processes to ensure efficient reporting of patient events and to grow a culture of safety within the organization.
5. REFERENCES
a. VHA Handbook 1050.01, National Patient Safety Improvement Handbook, dated March 4, 2011, DIRECT LINK.
b. VHA National Center for Patient Safety, JPSR Business Rules and Guidebook, dated July 2020, DIRECT LINK.
6. REVIEW
Attachment D.21 RFP 36C24224R0049 https://www.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number https://www.va.gov/vhapublications/publications.cfm?pub=2&order=asc&orderby=pub_Number https://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2389 https://dvagov.sharepoint.com/sites/VHAQPS/NCPS/PS_blog/PSM/JPSR/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHAQPS%2FNCPS%2FPS%5Fblog%2FPSM%2FJPSR%2FForms%2FAllItems%2Easpx&OR=Teams%2DHL&CT=1631106995192 https://dvagov.sharepoint.com/sites/VHAQPS/NCPS/PS_blog/PSM/JPSR/Forms/AllItems.aspx?viewpath=%2Fsites%2FVHAQPS%2FNCPS%2FPS%5Fblog%2FPSM%2FJPSR%2FForms%2FAllItems%2Easpx&OR=Teams%2DHL&CT=1631106995192 https://dvagov.sharepoint.com/sites/VHAQPS/NCPS/PS_blog/PSM/JPSR/Forms/AllItems.aspx?id=%2Fsites%2FVHAQPS%2FNCPS%2FPS_blog%2FPSM%2FJPSR%2FBUSINESS+RULES%2FJPSR+Business+Rules+and+Guidebook+July+2020.pdf&parent=%2Fsites%2FVHAQPS%2FNCPS%2FPS_blog%2FPSM%2FJPSR%2FBUSINESS+RULES&OR=Teams-HL&CT=1631106580946
This SOP will be reviewed at minimum at recertification, when there are changes to the governing document (for example, national policy or a health care accreditation body mandate), and any regulatory requirement for more frequent review.
7. RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of September 2026. In the event of contradiction with national policy, the national policy supersedes and controls.
8. SIGNATORY AUTHORITY
ERIC YEAGER
Quality Manager Date Approved: September 22, 2021
NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: SOPs are available at: Syracuse Medical Center Document Control SharePoint (DCS). https://dvagov.sharepoint.com/sites/VHASYR/svdc.
Attachment D.21 RFP 36C24224R0049 https://dvagov.sharepoint.com/sites/VHASYR/svdc/ https://dvagov.sharepoint.com/sites/VHASYR/svdc/
A-1
APPENDIX A
JOINT PATIENT SAFETY REPORTING SYSTEM (JPSR) PAPER CONTINGENCY
FORM
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