Safety And Health Standards For Risk Management

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F. Employees/Staff/Volunteers. The Employees/Staff/Volunteers shall.
1) Reports events: near misses, adverse or uncommon incidents with/without injuries via the event reporting application and/or to the Risk Manager and Director/Manager of the department.
2) Comply with Safety and Health Standards/Policies/Procedures that apply to their job responsibilities in an effort to provide Quality Patient Care and maintain a Safe environment. G. Risk Management Designee In the Absence of the Risk Manager.
1) The Risk Coordinator shall act as a designee for Risk Management, as appropriate and needed.
2) The Executive Director of Quality shall act as a designee for Risk Management
3) Should the Executive Director of Quality be unavailable, the
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Conclusions and subject information should not be included in the report.
4) The Risk Manager will be responsible for regular and systematic review of all event incident reports for the purpose of identifying, analyzing, evaluating exposures, and trends. If an undesirable exposure or trend is identified, the Risk Manager will develop recommendations for corrective action or refer issue to the appropriate committee/department chair/manager/director.
5) The Risk Manager will prepare the event trending reports to the Hospital Quality Improvement Committee (HQIC), the Board of Trustees (BOT), and the Medical Staff Executive Committee (MEC) at least quarterly.
6) If a notification is deemed a potential sentinel event, the Risk Manager is responsible for implementation of the sentinel event reporting policy and subsequent Serious Event Analysis (SEA).
7) The results of any SEA shall be submitted and intensively reviewed by Senior Management Administration, MEC, and the BOT. Applicable recommendations for Quality Improvement and Patient Safety shall be implemented at that time as appropriate.
8) Risk Identification systems include, but are not limited to: claims data, medical record requests, and patient complaints, environmental of care rounds, recalls, event reporting system, and collaborative relationships.
9) Risk Analysis: potential severity of loss associated with identified risk probability that loss will occur and frequency of loss
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