10 ovr reporting handbook

Occurrence Variance
Report and Sentinel
Reporting System
DR . MOHAMED RAMZY YOUSSEF
ER RESIDENT
QUALITY COORDINATOR , QPSD,MGH
‫عن‬ ‫التبليغ‬ ‫ونظام‬ ‫الحادث‬ ‫تقرير‬
‫الخطورة‬ ‫بالغة‬ ‫الحوادث‬

‫الغرض‬Purpose
Occurrence
Variance Report
is used to help
identify areas
needing
improvement or
recognition
‫تقرير‬ ‫يستخدم‬
‫للمساعدة‬ ‫الحادث‬
‫ومعرفة‬ ‫تحديد‬ ‫في‬
‫السقسام‬ ‫حاجة‬
‫.للتطوير‬

 Occurrence
Variance Report
(OVR) are internal
forms used to
document the
details of the
incident and the
investigation of an
occurrence and the
corrective actions
taken.
•‫عبارة‬ ‫الحوادث‬ ‫تقارير‬
‫داخلية‬ ‫استمارات‬ ‫عن‬
‫تفاصيل‬ ‫لتوثيق‬ ‫تستخدم‬
‫ذلك‬ ‫في‬ ‫والتحقيق‬ ‫الحادث‬
‫الجراء‬ ‫واتخاذ‬
.‫اللمزم‬ ‫التصحيحي‬

‫تستخدم؟‬ ‫متى‬‫؟‬When to use
 Injury to visitors or volunteers while
on the hospital premises
.‫المستشفى‬ ‫بمبنى‬ ‫تواجدهم‬ ‫أثناء‬ ‫المتطوعين‬ ‫أو‬ ‫الزوار‬ ‫إصابة‬
 Any incident which is not consistent
to routine patient care
.‫بالمريض‬ ‫العناية‬ ‫روتين‬ ‫مع‬ ‫تتعارض‬ ‫حادثة‬ ‫أي‬

 Occurrences not consistent with routine
operation of facility and /or adversely
affects, threatens the health or life of
patient, visitor, employee, student or
volunteer.
‫أو‬ ‫الروتينيية‬ ‫المسيتشفى‬ ‫عمليات‬ ‫ميع‬ ‫المتعارضية‬ ‫الحوادث‬
‫أو‬ ‫الزائر‬ ‫أو‬ ‫المريض‬ ‫حياة‬ ‫أو‬ ‫صحة‬ ‫يهدد‬ ‫وما‬ ‫السلبية‬ ‫المؤثرات‬
.‫المتطوع‬ ‫أو‬ ‫الطالب‬ ‫أو‬ ‫الموظف‬
 Loss or damage to personal or hospital
property.
.‫المستشفى‬ ‫ممتلكات‬ ‫أو‬ ‫الخاصة‬ ‫الممتلكات‬ ‫تضرر‬ ‫أو‬ ‫فقدان‬

‫يبلغ؟؟؟‬ ‫أن‬ ‫عليه‬ ‫يجب‬ ‫من‬
Who should reports
 Everybody
‫كل‬ ‫على‬ ‫يجب‬ /‫الجميع‬
. ‫التبليغ‬ ‫شخص‬

What to report ‫تبلغ؟‬ ‫ماذا‬ ‫عن‬
 Miscommunication
‫فهم‬ ‫سوء‬
 Accidental needle prick ‫بالبرة‬ ‫مقصود‬ ‫غير‬ ‫جرح‬
 Absconded ‫هروب‬
 Blood extraction ‫دم‬ ‫سحب‬
 Problem in cleanliness ‫نظافة‬ ‫مشكلة‬
 Medicines not transcribed
‫الطبية‬ ‫الوصفة‬ ‫كتابة‬ ‫عدم‬
 No response to call
‫للنداء‬ ‫الستجابة‬ ‫عدم‬

What to report ‫تبلغ؟‬ ‫ماذا‬ ‫عن‬
 Violation in standard precaution ‫الوسقائية‬ ‫المعايير‬
 Delays in:_______‫في‬ ‫:تأخير‬
 Non-availability of supplies/forms
‫النموذج‬ ‫أو‬ ‫المخزون‬ ‫توفر‬ ‫عدم‬
 Expired blood‫الدم‬ ‫صلحية‬ ‫انتهاء‬
 Wrong patient identification‫للمريض‬ ‫تعريف‬ ‫خطأ‬
 Other (specify:‫)حدد‬ ‫)أخرى‬

Policy ‫السياسة‬
1. Report the details of any
occurrence, which has an impacts
in the care of patient.
1‫على‬ ‫يهدد/يؤثير‬ ‫حادث‬ ‫أيي‬ ‫عين‬ ‫التفاصييل‬ ‫بإعطاء‬ ‫سقيم‬ .
.‫بالمريض‬ ‫العناية‬

2. OVR Form will be initiated
immediately after the
incident. And submit it to
your immediate supervisor
within the current work shift.
2‫بعد‬ ‫را‬ً‫ا‬ ‫فو‬ ‫تعبأ‬ ‫أن‬ ‫يجب‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ .
.‫العمل‬ ‫فترة‬ ‫خل ل‬ ‫رئيسك‬ ‫إلى‬ ‫تسلم‬ ‫وأن‬ ‫الحادث‬

3. The report will not be
used to criticize or blame
the actions of the staff
involved.
3‫إلقاء‬ ‫او‬ ‫لنقد‬ ‫التقرير‬ ‫يستخدم‬ ‫ل‬ ‫أن‬ ‫يجب‬ .
‫عنه‬ ‫المبلغ‬ ‫القسم‬ ‫على‬ ‫اللوم‬

4. Corrective actions shall be
taken to minimize risk of
injury and adverse outcomes.
Corrective action(s) shall be
documented.
4‫خطر‬ ‫من‬ ‫ليقلل‬ ‫يتخذ‬ ‫أن‬ ‫يجب‬ ‫التصحيحي‬ ‫.الجراء‬
‫والجراء‬ .‫لذلك‬ ‫المعاكسة‬ ‫والردود‬ ‫الضرر‬
‫في‬ ‫توثيقه/تسجيله‬ ‫يتم‬ ‫ان‬ ‫يجب‬ ‫التصحيحي‬
.‫المستندات‬ /‫السجلت‬

5. The Occurrence report
shall not be placed in
the medical record
(Patient File) nor in
Employee File.
5‫في‬ ‫الحادث‬ ‫تقرير‬ ‫يوضع‬ ‫ل‬ ‫ان‬ ‫يجب‬ .
‫أو‬ (‫المرضى‬ ‫)ملفات‬ ‫الطبية‬ ‫السجلت‬
.‫الموظف‬ ‫ملف‬ ‫في‬

6. Confidentiality: 6. ‫ي:ه‬ّ‫ه‬‫:السر‬
6.1 OVR reports will be handled in outmost
confidentiality.
a.‫تامة‬ ‫سرية‬ ‫في‬ ‫تسلم‬ ‫أن‬ ‫يجب‬ ‫الحوادث‬ ‫تقارير‬
6.2 OVR should not be duplicated with
exception of the TQM department.
a.‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬ ‫باستثناء‬ ‫ينسخ‬ ‫ل‬ ‫أن‬ ‫يجب‬ ‫الحادث‬ ‫تقرير‬
6.3 The information contained in the OVR
form cannot and will not be used against
any individual as basis for any disciplinary
action.
‫أي‬ ‫ضد‬ ‫تستخدم‬ ‫ولن‬ ‫يمكن‬ ‫ل‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫في‬ ‫الموثقة‬ ‫المعلومات‬ -‫جـ‬
‫تأديبي‬ ‫إجراء‬ ‫لي‬ ‫شخص‬

6.4 Hospital staff are NOT allowed to
discuss the contents of an OVR or the
events and circumstances relative to
the occurrence either with patient,
visitor or other members of the staff,
unless clarifying facts under
investigation with the proper
authorities.
-‫د‬‫ل‬‫والدحداث‬ ‫المحتوى‬ ‫يناقشوا‬ ‫أن‬ ‫المستشفى‬ ‫لموظفي‬ ‫يحق‬
‫أو‬ ‫الزائر‬ ‫او‬ ‫المريض‬ ‫مع‬ ‫سواء‬ ‫بالحادث‬ ‫المتعلقة‬ ‫والظروف‬
‫دراسة‬ ‫عند‬ ‫الحقائق‬ ‫توضيح‬ ‫عند‬ ‫إل‬ ،‫الرخرين‬ ‫المستشفى‬ ‫موظفي‬
.‫المعنيين‬ ‫المسئولين‬ ‫ومع‬ ‫المشكلة/الحادث‬

6.5 Discussion of general issues
on OVR for instructional or
education purposes with view
to improving patient care is,
however strongly encouraged.
‫الحادث‬ ‫تقرير‬ ‫في‬ ‫العامة‬ ‫المسائل‬ ‫مناقشة‬ ‫أن‬ -‫هـ‬
‫العناية‬ ‫لتطوير‬ ‫التعليم‬ ‫أو‬ ‫الرشاد‬ ‫لرغراض‬
.‫بشدة‬ ‫تشجيعها‬ ‫يتم‬ ‫بالمريض‬

6.7 Names of involved/
concerned person should not be
used.
‫القضية‬ ‫ب:ه‬ ‫المتعلقة‬ ‫الشخص‬ ‫اسم‬ ‫يستخدم‬ ‫ل‬ ‫أن‬ ‫يجب‬ -‫و‬
.‫فقط‬ ‫تعريف:ه‬ ‫رقم‬ ‫يستخدم‬ ‫بل‬

Occurrence Reporting flowchart
‫الحادث‬ ‫عن‬ ‫:التبليغ‬ Incident occurs
‫الحادث‬ ‫وقوع‬
Awareness of the occurrence
‫الحادثة‬ ‫عن‬ ‫التبليغ‬
Occurrence Variance Report Form is completed by the person
witnessed/affected by the occurrence
(Part A: Occurrence Details) and forward the duplicate copy to TQM Dept.
‫الحادثة‬ ‫من‬ ‫شهد/تضرر‬ ‫الذي‬ ‫الشخص‬ ‫قبل‬ ‫من‬ ‫تعبأ‬
(‫الشاملة‬ ‫الجودة‬ ‫ادارة‬ ‫قسم‬ ‫إلى‬ ‫ترسل‬ ‫الحادث(و‬ ‫تفاصيل‬ ‫أ‬ :‫الجزء‬
Immediate Supervisor evaluates occurrence if it meets the
Sentinel Event criteria (Part B: Immediate Supervisor
Notification)
‫الخطورة‬ ‫بالغة‬ ‫الحادثة‬ ‫كانت‬ ‫إذا‬ ‫ما‬ ‫المباشر‬ ‫المشرف‬ ‫يقيم‬
‫المباشر‬ ‫الرئيس‬ ‫تبليغ‬ (‫الجزء)ب‬

Meets Sentinel
Event Criteria
‫معايير‬ ‫توافق‬
‫الطارئة‬ ‫الحادثة‬
Refer to Sentinel
Event Committee
‫الحوادث‬ ‫لجنة‬ ‫تبليغ‬
‫الطارئة‬
Supervisor/designee carries
out required
investigation/corrective
actions (Part D: Action Taken)
‫التحقيق‬ ‫مسئولية‬ ‫المشرف‬ ‫يتحمل‬
‫المتخذ‬ ‫د:الجراء‬ ‫)الجزء‬ ‫)المطلوب‬
NoYes
If case of injury Physician should be informed and completes
the follow up as needed (Part C: Physician Follow-up)
(‫ج‬ ‫مطلوب)الجزء‬ ‫هو‬ ‫كما‬ ‫بالمتابعة‬ ‫يقوم‬ ‫المبلغ‬ ‫الطبيب‬ ‫الصابة‬ ‫دحالة‬ ‫في‬
‫الطبيب‬ ‫متابعة‬
Other
services/dept.
involved
‫المعنية‬ ‫الرخرى‬ ‫القسام‬
Document action taken on the OVR form (Part D)
by the Immediate Supervisor
‫على‬ ‫وسجل:ه‬ ‫محتاج‬ ‫هو‬ ‫كما‬ ‫التصحيحي‬ ‫الجراء‬ ‫أتخذ‬
‫المباشر‬ ‫الرئيس‬ ‫بواسطة‬ (‫د‬ ‫)الجزء‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬
No
Yes

Immediate Supervisor forwards the original copy of OVR and
refer the incident to the Supervisor/ HOD of the involved dept.
‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫الى‬ ‫نسخ:ه‬ ‫وترسل‬ ‫المسئول‬ ‫القسم‬ ‫عن‬ ‫الجوده‬ ‫تطوير‬ ‫لجنة‬ ‫مشرف‬ ‫بلغ‬
Involved dept. Supervisor/ HOD investigate &
document corrective action taken and his/her
recommendations to prevent recurrence on
the OVR form (Part D)
‫وإجراءه‬ ‫متابعت:ه‬ ‫ويسجل‬ ‫بالتحقيق‬ ‫يقوم‬ ‫المسئوول‬ ‫القسم‬ ‫مشرف‬
‫)د‬ ‫الجزء‬ ‫في‬ ‫الحادث‬ ‫تقرير‬ ‫إستمارة‬ ‫على‬ ‫)وتوصيات:ه‬
Inform initiating dept.
of the action taken
‫المسئول‬ ‫القسم‬ ‫ابل غ‬
‫المتخذ‬ ‫بالجراء‬
Supervisor
forwards
original copy of
OVR to TQM
Dept.
‫قسم‬ ‫الى‬ ‫يرسل‬
‫الجودة‬ ‫ادارة‬
‫الشاملة‬
TQM follows
up as
needed
‫ادارة‬ ‫تقوم‬
‫بالمتابعة‬ ‫الجوده‬
‫اللمزمة‬
TQM trends all
OVRs
‫الجودة‬ ‫إدارة‬ ‫تقوم‬
‫بتوجي:ه‬ ‫الشاملة‬
‫تقارير‬ ‫كل‬
‫الحوادث‬
TQM forwards
quarterly reports to
concerned areas,
QMC & Safety
Committee‫ادارة‬ ‫ترسل‬
‫تقارير‬ ‫الشاملة‬ ‫الجودة‬
‫كل‬ ‫دورية‬3‫للقسام‬ ‫أشهر‬
‫الجودة‬ ‫ادارة‬ ‫لجنة‬ ،‫المعنية‬
‫السلمة‬ ‫وإدارة‬

RESPONSIBILITIES ‫المسئوليات‬
1. Immediate Supervisors ‫الدارة‬ ‫وموظفي‬ ‫:المشرفين‬
- Consultation with the involved
employee(s).
.‫المعنيين‬ ‫بالموظفين‬ ‫الجتماع‬ -
-Resolution of problems should take
place when possible within and
between departments
‫ممكن‬ ‫وقت‬ ‫اقرب‬ ‫في‬ ‫توضع‬ ‫ان‬ ‫يجب‬ ‫دحيث‬ ‫للمشاكل‬ ‫الحلول‬ ‫وضع‬ -
.‫القسام‬ ‫بين‬

-Ensuring that all employees are aware of
OVR Reporting System; how to report
and the steps by steps procedure on
how to complete the form.
-‫التبليغ‬ ‫وكيفية‬ ‫الحوادث‬ ‫تقرير‬ ‫لنظام‬ ‫الموظفين‬ ‫معرفة‬ ‫من‬ ‫التأكد‬
.‫بخطوة‬ ‫رخطوة‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫وتعبئة‬
- Conduct immediate action and follow
up after the incident occurs.
-.‫الحادث‬ ‫وقوع‬ ‫بعد‬ ‫مباشرة‬ ‫فورية‬ ‫بمتابعة‬ ‫قم‬

- Document on the OVR the actions
taken and/or any corrective measures,
taken to prevent the recurrence of the
event.
-‫مقاييس‬ ‫أي‬ ‫او‬ ‫المتخذ‬ ‫الجراء‬ ‫الحادث‬ ‫تقرير‬ ‫في‬ ‫اكتب‬
.‫الحادث‬ ‫هذا‬ ‫مثل‬ ‫دحدوث‬ ‫لتمنع‬ ‫اتخذت‬ ‫تصحيحية‬
 Evaluates incident if meets sentinel event
criteria.
 ‫الخطورة‬ ‫بالغة‬ ‫الحادثة‬ ‫معايير‬ ‫يوافق‬ ‫كان‬ ‫إذا‬ ‫الحادث‬ ‫قيم‬

- Forward the completed (original)
OVR report form to the Total Quality
Management office within 72 hours
(3 days) of the occurrence.
-‫إدارة‬ ‫مكتب‬ ‫إلى‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫لم‬ّ‫ه‬‫س‬
‫رخلل‬ ‫الشاملة‬ ‫الجودة‬72‫من‬ (‫أيام‬ ‫)ثلث‬ ‫ساعة‬
.‫الحادث‬

- Conduct any further investigation
and document, report investigated
findings upon request of the
Hospital Administration the Quality
Management Committee or the
Safety Committee.
‫على‬ ‫بناء‬ ‫التحقيق‬ ‫موجودات‬ ‫وتوثيق‬ ‫إضافي‬ ‫تحقيق‬ ‫أي‬ ‫بعمل‬ ‫قم‬
.‫السلمة‬ ‫لجنة‬ ‫او‬ ‫الجودة‬ ‫ادارة‬ ‫لجنة‬ ‫المستشفى‬ ‫إدارة‬ ‫من‬ ‫طلب‬

2. The employee who witnesses
or discovers
2:‫الحادث‬ ‫اكتشفوا‬ ‫او‬ ‫شاهدو‬ ‫الذين‬ ‫.الموظفين‬
2.1 Immediate notification of
attending physician in case of
injury and Immediate
Supervisor
.‫القسم‬ ‫ومشرف‬ ‫المناوب‬ ‫للطبيب‬ ‫المباشر‬ ‫العل م‬ -

3. Attending Physician
4:‫الطباء‬ .
- Complete and document his/her
action(s) on the OVR form
immediately upon carrying out his
examination and/or the required
treatment or care.
‫إستمارة‬ ‫على‬ ‫المتخذ‬ ‫الجراء‬ ‫عن‬ ‫مختصر‬ ‫ملخص‬ ‫توثيق‬
‫اداء‬ ‫أو‬ ‫اختباره‬ ‫انهاء‬ ‫فور‬ ‫مباشرة‬ ‫الحادث‬ ‫تقرير‬
. ‫المطلوبة‬ ‫المعالجة‬

5. The Total Quality Management
Department is responsible for:
- Monitoring all OVR for follow up.
- Trending and preparing a
monthly summary.
‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬ ‫إن‬
‫عن‬ ‫:مسئول‬
-‫الحوادث‬ ‫تقارير‬ ‫كل‬ ‫متابعة‬
.‫المكتملة‬ ‫غير‬
-.‫شهري‬ ‫ملخص‬ ‫ووضع‬ ‫تجهيز‬

- Submitting a quarterly report to the
Quality Management Committee for
discussion and what action can be
done in the future to avoid
recurrence.
- Upkeep the file
‫مسئول‬ ‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬ ‫إن‬
‫:عن‬
-‫لجنة‬ ‫إلى‬ ‫سنوي‬ ‫ربع‬ ‫تقرير‬ ‫تسليم‬
‫ووضع‬ ‫للمناقشة‬ ‫الجودة‬ ‫إدارة‬
‫لتفادي‬ ‫المستقبليه‬ ‫المخططات‬

5. The Safety Officer
 Investigate all safety related incidents
 Organize a review team of selected Safety
Committee members to investigate
critical safety related occurrences.
6:‫السلمة‬ ‫مسئول‬ -
-.‫الحادث‬ ‫متعلقات‬ ‫جميع‬ ‫سلمة‬ ‫من‬ ‫التحقق‬
-‫السلمة‬ ‫لجنة‬ ‫اعضاء‬ ‫من‬ ‫مراجعه‬ ‫فريق‬ ‫تنظيم‬
.‫بالحادث‬ ‫المتعلقة‬ ‫السلمة‬ ‫ملظحظات‬ ‫لبداء‬

6. The Safety Officer
- Document the results of
investigation and corrective action
taken on the OVR form and
forwards it to the TQM.
6:‫السلمة‬ ‫مسؤول‬ -
-‫التصحيحية‬ ‫والجراءات‬ ‫التحقيق‬ ‫نتائج‬ ‫بتوثيق‬ ‫قم‬
‫قسم‬ ‫إلى‬ ‫وسلمها‬ ‫الحادث‬ ‫تقرير‬ ‫استمارة‬ ‫في‬ ‫المتخذة‬
.‫الشاملة‬ ‫الجودة‬ ‫إدارة‬

EQUIPMENTS AND FORMS
‫والنماذج‬ ‫الجهزة‬
1. Occurrence
Variance Report
Form
1..‫الحادث‬ ‫تقرير‬ ‫نموذج‬

Sentinel Event ‫متوقعة‬ ‫الغير‬ ‫الخطيرة‬ ‫الحوادث‬
 An unexpected occurrence
involving death, serious physical
or psychological injury to the
patient
‫الموت‬ ‫مثل‬ ‫المتوقعة‬ ‫غير‬ ‫الخطيرة‬ ‫الحوادث‬
.‫للمرضى‬ ‫الخطيرة‬ ‫والنفسية‬ ‫الجسدية‬ ‫والضرار‬

Reportable Cases ‫عنها‬ ‫التقرير‬ ‫يجب‬ ‫ظحالت‬
• An unanticipated
death
• Major permanent
loss of limb or
function, not
related to the
patient’s illness or
underlying
condition
• Infant abduction
. ‫المتوقع‬ ‫غير‬ ‫الموت‬
‫وظيفة‬ ‫او‬ ‫عضو‬ ‫فقدان‬
‫علقة‬ ‫له‬ ‫ليس‬ ‫جسدية‬
.‫تنويمه‬ ‫أو‬ ‫المريض‬ ‫بمرض‬
‫مولود‬ ‫اختطاف‬

 suicidal attempt
within the hospital
premises.
 Rape
 Physical assault of a
patient, staff or visitor
 Infant discharge to
the wrong family
‫داخل‬ ‫النتحار‬ ‫محاولة‬
.‫المستشفى‬
‫العتداء‬
‫على‬ ‫الجسدي‬ ‫العتداء‬
‫أو‬ ‫الموظف‬ ‫أو‬ ‫المريض‬
.‫الزائر‬
.‫الخطأ‬ ‫للعائلة‬ ‫طفل‬ ‫تسليم‬

• Significant hemolytic
transfusion reaction
involving administration
of blood or blood
products having major
blood group
incompatibilities
• Surgery on the wrong
patient or body part
• Significant Medication
errors (Overdose causing
death to patient.)
•‫للمريض‬ ‫عملية‬ ‫إجراء‬
‫المنطقه‬ ‫في‬ ‫أو‬ ‫الخاطئ‬
.‫الخاطئة‬
•‫الواضحة‬ ‫العلج‬ ‫أخطاء‬
‫المسببه‬ ‫الزائدة‬ ‫)كالجرعة‬
.(‫المريض‬ ‫لوفاة‬

Sentinel Event ReportingProcess
‫متوقعة‬ ‫الغير‬ ‫الخطرة‬ ‫الحوادث‬ ‫عن‬ ‫التبليغ‬ ‫عملية‬
1. Immediate notification
1:‫المباشر‬ ‫التبليغ‬ .
 Departmental Quality Improvement
Designee/Coordinator
(QIC/Designee)
.‫القسام‬ ‫جودة‬ ‫تحسين‬ ‫فريق‬ ‫منسق‬ / ‫ممثل‬

2. The QIC/D will notify
2:‫لغ‬ّ‫غ‬‫يب‬ ‫سوف‬ ‫المصمم‬ / ‫الجودة‬ ‫تحسين‬ ‫فريق‬ .
 Head of the Department
.‫القسم‬ ‫رئيس‬ -

3. The QID/C will call or bleep
(454) Quality Improvement
Coordinator by phone or in
person.
‫بإدارة‬ ‫الجودة‬ ‫منسق‬ ‫بإبل غ‬ ‫يقوم‬ ‫الجودة/المنسق‬ ‫ممثل‬
‫الرقم‬ ‫طلب‬ ‫طريق‬ ‫عن‬ ‫الشاملة‬ ‫الجودة‬454‫أو‬
.‫مباشرة‬ ‫مخاطبته‬

4. Occurrence
Report should be
submitted to the
Quality
Improvement
Coordinator
4‫يسلم‬ ‫ان‬ ‫يجب‬ ‫الحادث‬ ‫تقرير‬ .
.‫الجودة‬ ‫تحسين‬ ‫منسق‬ ‫إلى‬

5. Quality
Improvement
Coordinator will
conduct an
investigation
and interview
the involved
person and/or
any witness of
the event.
‫منسق‬ ‫يقوم‬ ‫سوف‬
‫بعمل‬ ‫الجودة‬ ‫تحسين‬
‫ومقابلة‬ ‫تحقيق‬
‫عنه‬ ‫المبلغ‬ ‫الشخص‬
‫على‬ ‫شاهد‬ ‫أي‬ ‫أو‬
‫الحادث‬

6. Quality Improvement
Coordinator will notify
the Sentinel Event
Committee and
convene for a meeting.
6‫الجودة‬ ‫تحسين‬ ‫منسق‬ ‫يقوم‬ ‫.سوف‬
‫الغير‬ ‫الخطيرة‬ ‫الحوادث‬ ‫لجنة‬ ‫بتبليغ‬
.‫لذلك‬ ‫اجتماعا‬ ‫وتعقد‬ ‫متوقعه‬

7. Root Cause Analysis will
be initiated and facilitated.
7‫السباب‬ ‫.تحليل‬‫يوضح‬ ‫سوف‬ ‫والنتائج‬
.‫ويقدم‬

8. Action plan will be designed
as appropriate and
implemented immediately.
8‫الولوية‬ ‫حسب‬ ‫على‬ ‫عمل‬ ‫خطة‬ ‫توضع‬ ‫.سوف‬
.‫الفور‬ ‫على‬ ‫وتطبق‬

9. All investigation and conclusion
documentation will be in the custody
of the Total Quality Management
Department and remained
confidential.
9‫في‬ ‫محفوظة‬ ‫تظل‬ ‫سوف‬ ‫الموثقة‬ ‫ونتائجه‬ ‫التحقيق‬ ‫كل‬ .
.‫ة‬ً. ‫بسري‬ ‫الشاملة‬ ‫الجودة‬ ‫إدارة‬ ‫قسم‬

10. Follow up assessment will be
conducted by SEC and the concerned
department within six (6) months of
the event
10‫الحوادث‬ ‫لجنة‬ ‫قبل‬ ‫من‬ ‫تكمل‬ ‫سوف‬ ‫القضية‬ ‫متابعة‬ .
‫أشهر‬ ‫ستة‬ ‫خل ل‬ ‫المعني‬ ‫القسم‬ ‫مع‬ ‫متوقعة‬ ‫الغير‬ ‫الخطيرة‬
.‫الحادث‬ ‫من‬

10 ovr reporting handbook

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