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My name is Jacqueline Mann and I work in the pediatric ICU at St. Peter's University Hospital in New Brunswick, NJ as a registered nurse.
All of our policies can be found in a folder on our homepage. The program we use to report incidents and near-misses is called Verge. On the bottom lefthand corner of the homepage, there is a Verge icon that you click on and it takes you right to program. Both are easily accessible and simple to use.
I have written a Verge and witnessed quite a few. One example I can think of was when I was working our vaccine clinic and a teenager was administered the vaccine because the parent lied about his age on the form and it was caught after the fact. (This happened before the vaccine was approved for the younger age groups and the incident was also reported to VERS.) After the incident, a re-briefing for the entire staff working the clinic was held. Stricter screenings were put into place and in our huddle before every clinic afterwards, the acceptable cut-off birth dates were reviewed and posted at every station. Leadership handled it appropriately and to my knowledge, it didn't happen again.
One of the biggest problems with reporting an incident is that policy states that the reporting should ideally occur in live time. Realistically, this isn't always possible- especially if the event is requires emergent intervention.

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Potential Serious Breach Reporting - Cindy Rooney

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Potential Serious Breach Reporting - Cindy Rooney

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My name is Cindy Rooney and I work for a pharmaceutical company. Due to security and privacy protocols, I was not able to submit the complete policy and was only able to provide the attached screenshot. My company has a portal for all company related policies and procedures. As a people manager, I was made aware of this portal previously, which contains other reporting policies (i.e.-Environment, Health & Safety Incidents and Reporting). In particular, the reporting policy that is relevant to my current role, working with clinical trials, is the 'Management of Potential Serious Breach' protocol. If an employee suspects a process or system-related deviation they can submit a request using the appropriate form as mentioned in the standard operating procedure (SOP). An example could be if an impact was made to the safety, rights, physical, or mental integrity of a clinical trial patient or the scientific value of the trial itself.

Along with my manager, we recently had to utilize this reporting policy for a system error, causing a potential serious breach. We recently transitioned to a new safety database, which houses all adverse events on our clinical trials. We noticed that reports were being submitted unintentionally with information that should not have been disclosed. Clinical trials , which were blinded, should not reveal if the patient received the study drug or placebo as this could jeopardize the reliability of the trial. However, due to this system error, reports were being submitted with information that should never have been disclosed. We used the reporting guidance outlined in this policy to take the appropriate steps to escalate the error and initiate an official investigation. The steps involved are: 1.) Evaluate, Report, and Request 2.) Triage and Assess 3.) Notify Health Authorities 4.) Investigate, Corrective Action Plan (CAPA), Follow-up, and Records Management. We are currently in the phase of having a CAPA created, which identifies the root cause, how to correct it, and prevent incidents in the future.

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My name is Kelly Loeble.  I work for a pharmaceutical company, and the "error-reporting" process for the company is called a "non-conformance."  I had to take screen shots of an empty report to send it to myself via email because there is a lot of security in my company's system.
I have had to do a "non-conformance" report for an adverse event report that was reported outside of my company's 24-hour or 1-business day window. Due to the FDA's stringent policies on adverse-event reporting, my company wants adverse events reported in 1 business day. I monitor agents' cases for certain quality items, including whether or not Adverse events or product quality complaints are missed. When I discovered an Adverse event that was "missed," or not reported within this 1 business day window, I had to initiate a non-conformance, of "NC." The report required a lot of managers' approvals and it required a corrective action plan to prevent the error from occurring in the future.

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I work at TUHS in Philadelphia PA. When we have any incidents happen in the hospital (e.g. patient leaving AMA, adverse reactions to medications, contraband, codes, medication errors, falls, etc.) we have to fill out an incident report via MIDAS. On any desktop you can open the MIDAS reporting system. You first will choose an "event". This will cascade into questions about if any patient was involved. You then fill out their last and first name and their DOB and room number if applicable. They are in our system so you chose the correct patient for the current admission on your floor (everything is listed when they are admitted into the hospital). Then you fill out a form about what has taken place. You write a brief explanation on the event and if any injury or pressure injuries may have taken place (if applicable, or write n/a). You then include who was involved (physician, nursing, administration, family of patient, etc.) Then you fill out who was notified. Then you fill out who entered the MIDAS report (someone can report for you).  It could also be an anonomyous entry.

When an employee is involved in a MIDAS, their managers are made aware. This allows for feedback for that specific employee.

I have submitted MIDAS' for patients leaving AMA, patient's eloping with their IVs in, patients who have drugs or other contraband on them, falls, improper transportation of patients, patients arriving to the floor with no chart or report called, and patients who have arrived to the floor with high risk medications running without giving report. Basically if any patient harm or potential harm is involved, it gets reported.

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My name is Jess Basciano. I work for Main Line Health, a hospital system in PA. The above PDF outlines our safety/event report policy. They define an "event" as any unplanned occurrence not consistent with the routine care of a patient, routine service of a department, or routine operation of the hospital or entity. We report falls, med errors/events, lab errors/events, safety hazards, equipment issues, skin issues, etc. The system we use to actually report an event is called RL Datix. You can either report anonymously, or with your hospital login. Any MLH employee can submit an event report. It asks who was involved (patient and staff), what was happening during the event, what the event was, who was notified.They are also responsible for verbally reporting the event to anyone involved (nurse, doctor, unit manager, supervisors, etc.). The event report is then reviewed by Patient Safety Specialists, who then reach out to everyone involved in the event to get a better picture of what occurred. Once they talk to everyone involved in the incident there is usually some sort of education or a new policy put into place.

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The event report should be completed if an unusual event has occurred to either a patient, visitor, their family, or an employee. Our nurse manager is the one that uploads the events into the system after we write a brief description on the event.  The physician must be notified and this does not go on the patients chart.  The Division Director will notify the Risk manager ASAP in the event a patient was harmed or injuried. What must be included is Status of individual, date and time, diagnosis or procedure being performed, physician name, room number, if MD was advised, and lastly a brief description of event. Only facts must be shared no assumptions. Also you must include any witnesses and who reported the event. I do know that when submitted we receive feedback within 24 hours of the event being reported.

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Jeanne Minsky

I work for Jefferson a health care system, that  strives to be a high reliable organization and encourages reporting every thing from, great catches, near misses, falls, medication errors, safety concerns, restraint use, violence and anything that does not uphold Jefferson values.

These reports are escalated, reviewed, and addressed with corrective action such as educating, adjustment in process, and or repair.

It is made clear that individuals that demonstrate reckless behavior that puts patients and or staff will be held accountable.

We utilize the On Point program.

The software icon for reporting is located on desk top upon logging in for the day.

It is easy to fill out and has hard stops. In other words it doesn't permit submission, until all necessary information filled out. It has an open narrative area to provide summary of the events. It has suggested guidance, such as cause, immediate action taken, how reported involved, and possible way too have prevented situation.

Upon submission you receive an e mail it was received. You will receive additional e mails when under review and closed.

It is a very easy to use and smooth process.

The post above is what was sent to all employees just prior to switching over to this program.

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Fw New OnPoint Reporting  Feedback Platform Goes Live 1021 Training Available

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I work for the Tower Health hospital system in Pennsylvania. The following policy discusses our patient safety plan and the precautions we take to maintain patient safety, as well as how we go about reporting issues in patient safety. The policy discusses the role individuals partake in to maintain patient safety, as well as the committee we have in place that is dedicated to the promotion of patient safety. The policy then goes on to explain the different types of detriments to patient safety and how they are classified. Policy also discusses the education and training for staff, patients and their families and even how to notify the family of an adverse event. I have submitted incident reports in the past, but never referenced the policy in doing so.

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Amy Bledsoe
I work for Capital Health in New Jersey.   Above you will find a copy of our Safety Reporting Systems, or as is known by staff, Verge Reports.    The system allows for all errors, no matter the nature, to be reported to upper management and senior leadership staff.  Staff is encouraged to submit reports within 72 hours of incident, and the report must be submitted by those individuals who directly witnessed the incident. Daily reports are provided to all management, and each unit is asked to review and address concerns specific to their department.   The reporting system is also overseen and reviewed by Quality Management to determine proper course of actions to rectify any problems that have occurred.
I have myself used the system on numerous occasions, as I have worked for the healthcare system for approximately 19 years. One incident that I can recall, is one that was involving a visitor who interfered with patient care during the triage process. The report was provided to my manager, as well as the manager of the visitor. I was not given the outcome of the report, but I was told that it was being handled by the managers of both departments involved. I have however submitted other reports and have not received follow up regarding the reports. I do know that it the responsibly of the leadership staff of each department to report how they have handled each report, so it is ensured that all reports are answered, and addressed in some manner.

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Scanned from a Xerox Multifunction Printer

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Reporting Safety Concerns/Annette Timlin 

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Reporting Safety Concerns/Annette Timlin 

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My name is Annette Timlin and I work for Johns Hopkins Hospital/University.  Where a work we have what we call HERO (Hopkins Event Reporting Online).

A HERO report can be filled out online by any JHH employee. The purpose of this is to report any events or situations that may have caused harm or could cause harm if not addressed.  The idea is that these safety issues are addressed by the appropriate persons and corrected.

I have used this before because a patient was able to see another patients results in the electronic portal. I know staff that I work with have put in a HERO report when the wrong labs were drawn.

HERO also allows us to recognize situations where near misses were not missed due to outstanding work by staff

Lastly on the HERO link you can also find a link for "The Signal". Which is a place to find system changes and lessons that have been learned across Johns Hopkins Medicine. The goal of this is to promote patient and staff safety.

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I work for a Catholic Health Services, in Long Island New York and this is their incident reporting policy form. I personally have not yet used this form but an important part of filling out the form is accurately filling in the time the incident took place as well as the type of incident. For example, if a patient fell and you were filling out this incident report, you would need to put the time the patient was found on the floor unless it was witnessed and the body part that was affected during the fall.