Occurrence Reporting

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Occurrence Reporting

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Occurrence Reporting
Building a Robust Problem Identification and Resolution Process

Kenneth Rohde    

Enhance patient care through effective occurrence reporting

You already capture the data. Now use it to make real improvements in your patient care.
This new resource by performance improvement expert Kenneth R. Rohde provides practical techniques to help you better analyze your occurrence reporting process, use your data to gain superior insight into why errors occur at your organization, and make improvements that decrease adverse events and enhance patient care.


  • Refine and improve your existing occurrence reporting system using a proven six-step approach
  • Arm yourself with the right data to become an effective change agent in your organization
  • Develop an occurrence reporting process that decreases adverse events and enhances patient care
  • Improve your report screening process
  • Easily identify trends through detailed, efficient analysis methods
  • Organize and prioritize your reports through effective coding
  • Implement successful corrective actions through ongoing tracking and evaluation

Table of Contents:

Chapter 1: Rethinking the Occurrence Reporting Process
Where Does Healthcare Go Wrong?
Healthcare Is Not the Only Industry That Does Problem Resolution and Identification (PIR)
Recommendations for an Ideal Process

Chapter 2: The PIR Process
Introducing the PIR Process
Six Steps in the PIR Process

Chapter 3: Reporting
Importance of Managing Reporting
Volume and Severity Must Dance Together
Reporting Thresholds
Tips for Normalization
Internal vs. External Identification of Issues
Two Simple Goals for Reporting Volume
Tips for Improving Your Reporting

Chapter 4: Screening
Screening Is Really Just Prioritization
Establishing Screening Criteria
Reporting Severity
Screening Quality Control
Tips for Improving Your Screening

Chapter 5: Analysis
A Graded Approach to Problem Analysis
Individual Analysis for High-Impact Problems and Moderate-Impact Problems
Aggregated Analysis for Watch/Trend Problems
Aggregated Analysis of Causes: The Big Payoff
Five Simple Data Questions
Trending and Aggregation Methods
A Typical Analysis Session
What Do Your Department Managers Really Want to Know?

Chapter 6: Coding
The Vital Process of Coding
Code Based on Data Utilization
A Practical Coding Structure
Coding the Event vs. Coding the Causes
Initial Event Codes
Code Cleanup Troubleshooting
Tips to Improve Coding

Chapter 7: Causing Change: Implementing Corrective Actions
Designing the Right Change
Getting Stuff Done
Dealing With External Commitments
Tips to Improve Implementation

Chapter 8: Tracking and Evaluation
Tracking Actions
Evaluation of Actions
Evaluating the Effectiveness of the PIR Process

Chapter 9: Taking Your PIR Process to the Next Level
Looking Toward the Future

Look at the 90 occurrence reporting tools included!

AviationSafety Reporting System incident report excerpt
National Transportation Safety Board incident report excerpt
FDA adverse event report sample
IAEA initiation report sample
CPSC incident report
Quick guide to avoiding weaknesses: Build strengths in your PIR process
Six steps of the PIR process
Self-assessment questions to evaluate reporting, screening, analysis, coding, implementation, and tracking and evaluation
Reporting stability
Reporting by department
Combine volume and severity to get the best picture
Example: Calculating relative activities for use in normalization
Tips for improving your reporting
Screening helps us know what to do next
Screening work flow
Expectations for screening
Example of converting word severity scales to numerical scales
Prioritizing performance improvement activity and corrective actions
What we need to know to screen an issue
Which issues should we check the severity on?
NCC MERP Index for Categorizing Medication Errors
Comparison of severity scales
Significant event management process
Model screening matrix
Typical notifications worksheet
Balance your analysis efforts
Analysis work flow
Root cause analysis work flow
Expectations for the ideal root cause analysis team, and team sponsor
Expectations for an ideal apparent cause analysis
Typical fields in a significant event database
Significant event database flow chart
Five simple questions our data analysis must answer
Tools to help answer the magnitude question, the direction question, and the variability question
Highly variable data set example
Tools to help answer the rate of change question
Key considerations for effective time series graphs
Time series analysis of reporting volume and harm events
Data fields for top-level time series graph
Histogram analysis of events by process (one dimension) and event category (two dimensions)
Four-quadrant graphs allow you to make easy value decisions
Comparison/correlation analysis of volume and severity by department
Model agenda for a trend meeting
Key ways to improve your analysis
Comparison of centralized and distributed coding approaches
Coding all causes
A practical coding process includes three major types of codes
Typical values for “who was impacted”
Typical role codes and physical location codes
Examples of a process coding approach and an activity coding approach
Expectation codes
Culture of safety expectations
Nature of impact codes
Severity codes
Moral patient harm severity codes
Liability harm severity codes
Process impact severity codes
When coding is typically performed
Table of codes and possible intervention
Examples of permanent and transitory corrective actions
Typical definitions of qualitative benefits
Relationship of permanence and predictability
Scope and timing characteristics of corrective actions
Checklist for good corrective actions
Action plan to prevent recurrence form
Feeding the four outputs of action plan
Additional coding to support a basic common cause analysis, a basic benefits report, a corrective actions analysis, and to support accountability tracking
What can you do with the master action list?
Tips for prioritization
Alignment of responsibility for the most important corrective actions
Quick guide to causing change and implementing corrective actions
When should we consider removing a corrective action?
Key indicators to evaluate the effectiveness of your PIR process
Tracking and evaluation


Kenneth R. Rohde is president of KR Rohde LLC, a consulting company specializing in helping organizations deal with their problems. He brings more than 32 years of experience in quality management to his work with hospitals, medical centers, power plants and high-risk manufacturing facilities across the country. Mr. Rohde's roles in performance improvement and project management make him uniquely qualified to assist medical staffs and hospital leaders develop solutions to their toughest challenges. He instructs, speaks, and consults in the areas of error reduction strategies, root cause analysis, improving performance through process simplification, error reduction through effective procedure writing, apparent cause analysis, engineering effectiveness and error reduction, failure modes and effects analysis, effective data collection, analysis and trending, patient safety evaluation and improvement, change management, corrective action program evaluation and redesign, human performance evaluations, and procedure error reduction. Mr. Rohde also specializes in technology-based approaches to preventing human errors.

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Published: June 2011