S02 - Attachment G CERS Incident Death Reporting Manual.pdf

Community Engagement and Reintegration

Service (CERS)

Incident / Death

Reporting/Documenting

Process

CERS INCIDENT-DEATH REPORTING MANUAL, January 3, 2020

Table of Contents

• Page 3: Definitions

• Pages 4-5: Incident/Death Reporting/Documenting process/format

• Page 6: Joint Patient Safety Report (JPSR) instructions

• Page 7: Behavioral Flag instructions

• Page 8: Do’s and Don’ts tips

REPORTABLE INCIDENTS

• All instances where a veteran has been harmed, allegedly abused, (physically, psychologically, sexually, or verbally), or involved in an event that could potentially be harmful.

• All deaths from all causes.

DEFINITIONS

ADVERSE EVENT is an untoward incident, therapeutic misadventure, iatrogenic iinjury (caused by medical or diagnostic procedure) or unexpected occurrence directly associated with care or services provided to a Veteran that results in negative consequences for that Veteran. An adverse event may result from acts of commission or omission. All adverse events require reporting and review.

CLOSE CALL / NEAR MISS is an event or situation that could have resulted in an Adverse Event but did not, either by chance or through timely correction or intervention. Close Calls receive the same level of scrutiny as Adverse Events as they present opportunities for learning and developing preventive strategies and actions.

INTENTIONALLY UNSAFE ACT is any event that results from a criminal act, a purposefully unsafe act, an act related to alcohol or substance abuse by an impaired provider and/or staff, or event involving alleged or suspected patient abuse of any kind.

SENTINEL EVENT is a type of Adverse Event involving an unexpected occurrence that results in death, serious physical or psychological injury or risk thereof. It is an event resulting in an unanticipated death or permanent harm (i.e., loss of function) or serious temporary harm, not related to the natural course of the patient’s illness or underlying condition.

CERS PATIENT INCIDENT (ADVERSE EVENT) AND DEATH

REPORTING/DOCUMENTING PROCESS/FORMAT

The VA or Contract Employee who first becomes aware of an actual or potential adverse event, regardless of position or discipline, will document event in CPRS, report to CERS QM team at VHAGLACERSIncident@va.gov, and when appropriate, initiate Joint Patient Safety

Report (JPSR) entry.

• VASH Contract staff will: (a) immediately report to VA Liaison using the format below and e-mail or fax to Liaison, (b) document in CPRS, describing the event, not mentioning that incident report done.

• THP (Transitional Housing Program- GPD and HCHV) staff will immediately report to their

VA Liaison.

• VA staff will: (a) report to his/her VA supervisor; (b) when appropriate, enter event in JPSR;

and always (c) report incident via encrypted e mail to CERS Incident Reporting group, VHAGLACERSIncident@va.gov, by addressing items #1 through #12 items on page 5.*

• The following incident types DO NOT require JPSR submission. ONLY document event in CPRS and e mail incident report to VHAGLACERSIncident@va.gov

✓ Death from natural causes

✓ Criminal activity

✓ Disruptive behavior

• Format:

In e mail “subject“ line specify: Program, incident type, incident date JPSR number (if done).

NEVER include Patient identifiers. Example: Dom, Fall with injury, 12/23/19, PSR 99999999

[For suicide ideation or behavior, see item #13 on page 5 for additional documentation and reporting requirements.] mailto:VHAGLACERSIncident@va.gov, mailto:VHAGLACERSIncident@va.gov, mailto:VHAGLACERSIncident@va.gov

*Send an email to VHAGLACERSIncident@va.gov to report an incident, addressing items #1 through #12 (may be copied and pasted onto email):

1) Pt full name and SS# (last 4)

2) Incident Type/ death

3) Incident/ death Date

4) VA Program (DOM, HUD-VASH, THP, HPACT, VCED, Outreach, Welcome Center, etc.)

5) Location: Facility/Contract: (PATH, VOA, New Directions, etc.)

6) Name, Professional Title and Telephone of Staff submitting report

7) Brief description of circumstances of incident/death.

8) Intervention/ action/Follow up plan

9) If death, indicate Cause, if known

10) If death, how you were notified (Program, Contract, Next of kin, etc.)

11) If death, how you verified (Coroner, police, next of kin, etc.)

12) Was JPSR submitted? (note exemptions on page 4). If yes, enter JPSR number.

13) In case of suicide ideation/ suicide behavior/ suicide attempt/death by suicide:

a. Notify the Suicide Prevention Coordinators (SPC) https://vaww.portal.gla.med.va.gov/sites/spp/default.aspx

b. Complete relevant Suicide Risk Evaluation or Report in CPRS

14) If death

a) Request CPRS death flag from GLA Business Office by e mailing the following information to the VHAGLAVeteranDeathNotification@va.gov with CC to Lea Sasson and Edna Naito-Chan.

▪ Name and last 4

▪ Date of death

▪ Program

▪ Cause, if known

b) Call Chaplain Herman Kemp at 310.415.9377 when appropriate and provide:

• Full name a and full SS#

• Date of death

All additional email correspondence regarding a specific incident/ death should include patient identifiers—in body of response, never in subject line—and sender’s signature block, which includes sender’s contact information.

mailto:VHAGLACERSIncident@va.gov, https://vaww.portal.gla.med.va.gov/sites/spp/default.aspx mailto:VHAGLAVeteranDeathNotification@va.gov

JOINT PATIENT SAFETY REPORT (JPSR) CHEAT SHEET

1. Enter GLA Portal

2. Click on GLA links

3. Click on Joint Patient Safety Report link

4. Click on green access box

5. Click on certificate prompt

6. Enter your PIN

7. Click on Department of Veteran Affairs (right emblem)

8. In “CAMPUS” prompt enter GLA

9. Follow pull down prompts

10. In “VETERAN NUMBER” prompt enter Social security number, also enter it in description narrative section.

11. Click Submit when done.

***The following incident types do not require reporting in JPSR***

• Death from natural causes

• Criminal event

• Disruptive behavior

BEHAVIORAL FLAG CONSULT NEW PROCEDURE

• On your desk top, open VA Shortcuts folder

• Click on VISN

• Click on DBRS (Disruptive Behavior Reporting System)

• If you need assistance call Lea (310.268.3275 from outside or internal X53275) or Edna (310.478.3711 X 47739) if you need assistance

Announcing the new DBRS!

Have you experienced or observed threatening or aggressive behavior while working on GLA premises? If you wish to report such incidents to the Disruptive Behavior Committee, there is now an easy, direct way to do so right from your computer workstation. The Disruptive Behavior Reporting System (DBRS) is a web-based application that guides you through the process of filing a report.

You can access the DBRS via the web link https://cfm.vssc.med.va.gov/dbr/main.cfm or via the DBRS icon located in the desktop folder VA Shortcuts à VISN (you can copy and paste the icon directly on to your desktop for quick access later).

The DBRS simplifies the process of alerting the DBC to problem behavior occurring anywhere within the VA Greater Los Angeles Healthcare System, with the goal of promoting a safer and more positive environment for patients, staff and visitors.

5.26.16 ls https://cfm.vssc.med.va.gov/dbr/main.cfm

INCIDENT REPORTING “DO’S AND DON’TS”

A. Documentation/reporting:

1. CPRS

• Be prudent; keep in mind that patients have access to their record and it is disclosable in court.

• Do not mention “incident report done” or “QM notified.”

• Do not add QM staff as additional signers.

2. JPSR

• Be prudent and concise. Add Social Security number in Narrative description section.

3. ALL DOCUMENTATION VENUES

• Always add intervention/follow-up/corrective action when documenting occurrences in all your documentation venues.

B. E mail etiquette

1. In “subject” line, always specify:

✓ Program

✓ incident type

✓ incident date

✓ JPSR number (if done)

✓ NEVER post patient identifiers (name and/or SS#)

2. Add signature block in all e mails

3. Include initial attachment with each response or at least enter patient identifiers and issue in the chain’s responses.

4. When multiple recipients in message, address specific questions to the person you want answers from.

Questions? Please contact Lea Sasson at (310) 268-3275 or ext. 53275 or Edna Naito-Chan at (310) 478-3711, ext. 47739