Many occurrences do not require an investigation or further action to be taken. Many occurrences are simply tracked and trended for significance, which provides an indication as to the need for further investigation. In the event of a reported infection, if there is only one patient post-op infection, this should not cause a great deal of concern. The occurrence should be tracked and trended to see if there are other reported post-operative infections. If there are other reported infections an investigation should take place to ascertain the possible cause. Having investigated infections in the past we have learned that often times post-op infections can be due to poor hygiene by the caregiver when changing dressings, poor instructions to the caregiver when providing discharge instructions, or due to something in the facility that is causing the infections.
The approach outlined is the same approach that should be taken for any occurrence that requires further investigation:
In summary, occurrences are events that happen outside of the normal course of the day. These events cause or create inefficiencies in the delivery of patient care, cost the facility money, or can result in an injury to the patient or an employee. Tracking and trending is an approach that will help you understand the severity of the of the issue and whether it was a single event or an ongoing problem that needs to be addressed. In addressing the occurrence a “close the loop” approach is best, identify the issue, develop an approach to resolve the issue, implement the actions to resolve the issue and then reassess to ensure the issue has been completely resolved. If the issue has not been resolved we go back to step 2 and develop new approaches.