HOSPITAL NAME

INSTITUTIONAL POLICY AND PROCEDURE (IPP)

Department:
Manual:
TITLE/DESCRIPTION
OCCURRENCE VARIANCE REPORT SYSTEM
EFFECTIVE DATE
REVIEW DUE
REPLACES NUMBER
APPROVED BY

Section:
POLICY NUMBER
NO. OF PAGES

APPLIES TO

PURPOSE

To provide a systematic, standardized hospital-wide mechanism to identify and/or to develop prevention

/improvement programs which have direct or indirect adverse effect on patient care; and which represent a
potential hazard to patients, visitors, volunteers, trainees, employees or the facility as quality improvement
approach. OVR shall be used as a mechanism for monitoring, Quality Improvement in a Non Punitive
Approach.
DEFINITION

1. An Occurrence: any occurrence that is not consistent with the routine operation which happens at the
premises, Housing (owned, lease), external Activities, and transportation or whenever there is an unusual or
unexpected response by a patient to standard treatment or medical intervention, any routine operation that
adversely affects or threatens the health or life of patient, visitor, employee, trainee or volunteer; or which
involves loss or damage to personal or Hospital property. An occurrence also includes any event might result
in any other adverse situation that violates the code of conduct or a claim against the organization.
2. Occurrence Variance Report (OVR): an internal form _____________ used to document the details of the
occurrence/event and the investigation of an occurrence and the corrective actions taken.
3. On-the-job Occurrence: an occurrence that takes place in the Hospital or outside the premises when the
employee is carrying out his/her duties, such as Home Health care staff.
4. Adverse Drug/Instrument Event: any occurrence in which the use of medication (drug or biologic) at any
dose, a medical device, improper administration of medications or a special nutritional product (for example
dietary supplement, infant formula, medical food) may have resulted in an adverse outcome in a patient.
5. Adverse Event: are unexpected incidents, therapeutic misadventures, iatrogenic injuries or other adverse
occurrences directly associated with care or services provided. Adverse events can be categorized as either a
sentinel event or near miss that results from acts of commission or omission (e.g. administration of the
wrong medication, failure to make a timely diagnosis or institute the appropriate therapeutic intervention,
adverse reactions or negative outcomes of treatment, etc.). Some examples of adverse events include: patient
falls, medication errors, procedural errors/complications, completed suicides, para suicidal behaviors
(attempts/gestures/threats), and missing patient events.
6. Sentinel Event: A Sentinel Event is an unexpected occurrence involving death or serious physical or
psychological injury, or the risk thereof, not related to the natural course of a patients illness or underlying condition.
The phrase serious physical or psychological injury specifically includes loss of limb or function. The phrase or the
risk thereof includes any process variation for which a recurrence would carry a significant chance of a serious
adverse outcome and includes delays in diagnosis and treatment. The following events are considered Sentinel Events
even if the outcome is not death or major permanent loss of function:

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Suicide
Homicide
Surgery on the wrong patient or body part
Impairment (major/permanent loss of bodily function i.e. serious physical or psychological injury or
the risk thereof) that is not the result of the patients underlying medical condition.
Any unexpected death that is not the result of the patients underlying medical condition
Rape

Child Abduction or discharge to the wrong family

Hemolytic Blood Transfusion
7. Near Miss: Is an event or situation that could have resulted in an accident, injury or illness, but did not,
either by chance or through timely intervention. An example of a Near Miss would be: surgical or other
procedure almost performed on the wrong patient due to lapses in verification of patient identification but
caught at the last minute by chance. Near misses will receive the same level of analysis as Adverse Events
that result in actual injury, and for learning purposes.
8. Malpractice: Improper or unethical conduct or unreasonable lack of skill by a holder of a professional or
official position, often applied to physicians, dentists, nursing to denote negligent or unskillful performance
of duties when professional skills are obligatory. Malpractice is a cause of action for which damage are
allowed.
9. Variation: the differences in results obtained in measuring the same event more than once. The sources of
variations can be grouped into two major classes: common causes and special causes. Too much variation
often leads to waste and loss, such as the occurrence of undesirable patient health outcomes and increased
cost of health services.
RESPONSIBILITY

1. It is the responsibility of the person in charge to ensure that all OVR involving patient, personnel, or
visitor injury, occupational illness to assure the stability of any injury in the first priority and have the
OVR completed.
2. Resolution of problems identified thorough OVR system should always take place when possible within
and between department(s) by responsible supervisory and management personnel including consultation
with involved employee.
3. The Employee who witness or discover an occurrence has the professional obligations and responsibility
for:
a. Immediately notifying:
i. The physician on call if the occurrence involves any question of patient or employee
injury or harm.
ii. The area supervisor.
b. Initiating the OVR form before the end of the occurrence shift.
c. Submitting the original of the OVR form to the supervisor on duty for completion.
4. The Supervisor is responsible for:
a. Ensuring that all employees are aware of OVR system and how to report and process of OVR
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5.
6.

7.

8.

form.
b. Conducting immediate follow-up of the occurrence by initiating and documenting on the OVR
the actions taken at the time of the occurrence and any corrective measures taken to prevent a
recurrences of the events.
c. Ensuring thorough and accurate completion of the OVR form.
d. Forwarding the completed OVR form to concerned person and CC to the office within 72 hours
of the occurrence.
e. Conducting any further investigation and documenting investigative findings of the reported
occurrence upon request of the hospital administration, the QM committee or the safety
committee.
The Physician: she/he is responsible to document a brief statement of his/her action(s) on the OVR form
immediately upon completion the patient / employee examination and or the required care.
QM Department is responsible for:
a. Monitoring all OVR(s) for follow up to the proper authorities so that necessary steps may be
taken by those in-charge to resolve the situation if necessary.
b. Trending and preparing a monthly summary of all reported occurrences.
c. Submitting a quarterly report to the TQM committee for discussion and further action if deemed
necessary by QM committee.
d. Maintaining a file of all OVR submitted to the TQM office for 3 years.
The Safety Officer is responsible for:
a. Investigating all safety related occurrences for investigation initiated by the TQM department
b. Activating a Review Team of selected committee members to investigate critical safety related
occurrences.
c. Documenting the results of investigation and corrective action taken on the OVR form.
d. Returning the completed form to the TQM office.
e. Reviewing monthly summary data to determine if safety hazard issue exists and report to safety
committee.
Annual Evaluation
An annual evaluation of the OVR system shall be conducted and reported to the QM committee as part
of the annual evaluation of the QM plan by the QM director.

CROSS REFERENCES
POLICY

1. It is the responsibility of all employees to immediately report the details of any occurrence that may
negatively impacts the care of a patient.
2. The OVR form will be initiated immediately following any unusual or dangerous occurrence.
3. All sections of the OVR form must be completed and submitted to the immediate supervisor within the
current work shift.
4. This report is to be used to identify the facts surrounding the occurrence and will not be used to criticize or
speculate on actions of the staff involved
5. Corrective actions shall be taken to minimize risk of injury and adverse outcomes. Corrective action(s) shall
be documented.
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6. The OVR form shall not be photocopied or placed in the medical record. The terms incident and error
shall not be used in the medical record when making an entry regarding an occurrence or the results of an
occurrence.
7. It is the responsibility of patient Safety manager to supply the Safety Committee with a quarterly summary
of patient incidents.
8. In case of Adverse Drug Reactions, follow the Adverse Drug Reactions Reporting Policy ________.
9. In case of Medication Errors, follow the Medication Errors Reporting Policy # _______
10. Confidentiality:
a. All OVR shall be handled and maintained in a confidential manner, with access to such
documentation restricted to authorized individuals.
b. OVR shall not be duplicated, with exception of the TQM department, when deemed necessary.
c. The information contained in the OVR form cannot and shall not be used against any individual as the
sole basis for disciplinary action.
d. Hospital staff is not at liberty 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.
e. Discussion of general issues on OVR for instructional or educational purposes with view to improving
patient care is, however, strongly encouraged.
f. Names of involved / concerned person should not be used. Use ID #
PROCEDURE

General instructions: (guidelines how to use the Form)

a. Use of OVR template.
b. If not possible use blue ink. Avoid pencils, in clear legible handwriting
c. Write objective view and comments. Avoid personal opinions.
d. The OVR form consists of the following sections
i. Upper right corner: Patient Information
ii. Occurrence Details: (by the person witnessed / affected by the occurrence)
iii. Person(s) affected
iv. Affected employee information
v. Occurrence brief description
vi. Immediate action taken
vii. Witness(es) Information
viii. Supervisor Notification (included decision of sentinel event)
ix. Physician Follow Up Notification
x. Severity of Injury:
1. Slight / minor treatment: the incident resulted in abrasion, reddening of the skin, a bruise or
other apparently minor damage to tissue. The treatment required was non-invasive for e.g.
topical ointment, dressing or ice packs. Medication incidents that may require monitoring such
as changes in vital signs or lab tests.
2. Moderate injury: the incident resulted in hemorrhage, tissue impairment and required clinical
intervention. For e.g. suturing, first and second degree burns. Medication incidents with
potential for serious outcomes that require intervention and monitoring.
3. Serious injury: the incident resulted in fracture, hemorrhage, aspiration, third degree burns,
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xi.
xii.
xiii.
xiv.

serious drug reaction or the incident resulted in admission to hospital (if outpatient), transfer to
critical care area, or increase in length of stay (inpatient).
4. Death
Integrated Occurrence Strategy (as needed) Follow up, by responsible person/department, to include
recommendations
TQM office comments
Type of occurrences
Contributing factors

FORMS

OVR Form
EQUIPMENT
REFERENCES

www.jcaho.org/sentinel/se_glsry.htm
APPROVAL:
Name

Signature

Date

Prepared by
Reviewed by
Approved By
Approved By
Latest Revision Approved By

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