The quality manager VHA Handbook There is an unwavering Adverse events that Numerator: 13 ÷ 20 = 65% for surgical services 1004.08 Disclosure ethical obligation to cause harm to Number of adverse found a number of of Adverse Events to disclose to patients patients on surgical events that caused Currently, 65% of instances in which Patients harmful adverse events services should be harm to patients that adverse events that adverse events that that have been disclosed to the were disclosed to cause harm to caused harm should sustained in t he course patient or personal patients or personal patients on surgical have been disclosed of care, including cases representative representatives as services are being to patients or personal where the harm may [unless patient is measured by a note disclosed to the representatives were not be obvious, or deceased, template completed by patient or personal not disclosed. where there is potential incapacitated, or the provider representative. for harm to occur in the otherwise unable to __________________ future. take part in the Denominator: process, and there is Total number of no personal adverse events that Exclusion(s): representative]. caused harm to Patient is deceased, patients on surgical incapacitated, or services otherwise unable to Method: Record take part in the process, review and there is no personal representative. Sample size: 100% Time frame for data collection: Past 6 months MODULE 2 MODULE 3 MODULE 4
The quality manager for surgical services found a number of instances in which adverse events that caused harm should have been disclosed to patients or personal representatives were not disclosed. VHA Handbook 1004.08 Disclosure of Adverse Events to Patients There is an unwavering ethical obligation to disclose to patients harmful adverse events that have been sustained in t he course of care, including cases where the harm may not be obvious, or where there is potential for harm to occur in the future. Exclusion(s): Patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative. Adverse events that cause harm to patients on surgical services should be disclosed to the patient or personal representative [unless patient is deceased, incapacitated, or otherwise unable to take part in the process, and there is no personal representative]. Numerator: Number of adverse events that caused harm to patients that were disclosed to patients or personal representatives as measured by a note template completed by the provider __________________ Denominator: Total number of adverse events that caused harm to patients on surgical services Method: Record review Sample size: 100% Time frame for data collection: Past 6 months 13 ÷ 20 = 65% Currently, 65% of adverse events that cause harm to patients on surgical services are being disclosed to the patient or personal representative. MODULE 2 MODULE 3 MODULE 4
pe_btb_mod4_handouts_final_06162014.docx