II.

DETAILS OF CONCERN REQUIRING CORRECTIVE OR PREVENTIVE ACTION:

3 (Number of Accident reports) / 33(Census for the month of October) x

100= 9%
3 (Number of Incident reports related to Aggression) / 33(Census for
the month of October) x100= 9%
there were a total of 3 Accident reported and 3 reported incidence of
injury due to aggression because of patients disturbed behavior.
Attached herewith are the scanned report from the Nurses Report
Book.

III. IMMEDIATE ACTION TAKEN

Circle meeting regarding the data being collected for the month of October
2016 related to injuries accident and incident due to Aggression.

Immediately informed the HOP, Consultants and Physician-in-Charge the

result of the KPI so that they can review of the medications and therapies
given.

Informing the staff regarding the result of the KPI so that they are going to be
more vigilant and aggressive when it comes to unusual patients behavior.

IV. ROOT CASE ANALYSIS

Some of the incident and accident documented includes self-inflicted injuries

and punching.
Injuries are minor that are managed with first aid treatment and were
referred to Physician-in-Charge, some incidents are being referred to Pavilion
7 Medical-Surgical Infirmary for further evaluation and management but
some did not require further interventions. Close observation was done to
check injuries as per doctors order.
Patient that are involved are mostly old patients. Some are newly admitted
patients.

V. PROPOSED ACTION:

Proper medication administration and implementation of therapeutic

activities as ordered by the psychiatrist.
Monitoring of patients behavior with the help of Nurses and Nursing
Attendants on duty. Immediate referral of unusual behavior should be
addressed properly that can result harm to self or to other patients.
Personnel should be vigilant at all times. We should always prioritize patient
safety. Frequent irregular rounds should be done and daily activities should be

implemented to divert patients attention into more productive activities.

Activities also help patients bond with each other and promote social
interactions.
In the event that there is no change in patients behavior within 2-3 weeks of
treatment, immediate referral to PIC should be done to be able to review
medications appropriate for the patients behavior.
Circle meeting is necessary to determine any lapses between patients and to
have a picture on what has happened within 24hours.
Incident Report should be accomplished accordingly, injuries sustained should
be properly documented and referred to the Physician on Duty.