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OVR
Occurrence
Variance Report
‫اﻟﺤﺪث‬ ‫اﺑﻼغ‬ ‫ﺗﻘﺮﻳﺮ‬
Prepared by..
Dr.Rania Mohamed
B.Ph ,CPHQ , TeamSTEPPS Master Trainer , Lean Champion

Agenda
01
02
03
04
05
‫...؟؟‬ ‫اﻟﺣدث‬ ‫اﺑﻼغ‬ ‫ﺗﻘرﯾر‬ ‫ﻣﺎھو‬
‫...؟؟‬ ‫اﻻﺑﻼغ‬ ‫ﻟﺗﻘﺎرﯾر‬ ‫ﻧﺣﺗﺎج‬ ‫ﻟﻣﺎذا‬
‫اﻟﻧﻣوذج‬ ‫ﻣلء‬ ‫وﺧطوات‬ ‫اﻟﺗﺑﻠﯾﻎ‬ ‫ﻧظﺎم‬ ‫ﻣراﺣل‬
‫اﻟﻣﺻطﻠﺣﺎت‬ ‫ﻣﻌﺎﻧﻲ‬
‫واﻟﻣﺳؤوﻟﯾﺎت‬ ‫اﻷدوار‬

‫اﻟﺤﺪث‬ ‫اﺑﻼغ‬ ‫ﺗﻘﺮﻳﺮ‬
Occurrence variance reports (OVR)

‫اﻟﻣرض‬ ‫ﻣن‬ ‫)ﺑدﻻ‬ ‫اﻟﻣرﯾض‬ ‫وﺳﻼﻣﺔ‬ ‫ﺻﺣﺔ‬ ‫ﯾﮭدد‬ ‫أو‬ ‫ﯾؤﺛر‬ ‫ﻣﺄﻟوف‬ ‫ﻏﯾر‬ ‫ﺣدث‬ ‫أي‬
‫ﻟﻠﻣرﻛز‬ ‫وﺧﺳﺎرات‬ ‫أﺿرار‬ ‫وﯾﺗﺿﻣن‬ ‫اﻟﻣوظف‬ ‫أو‬ ‫اﻟزاﺋر‬ ‫أو‬ (‫اﻷﺳﺎﺳﻲ‬
‫اﻟﻣرﻛز‬ ‫ﺿد‬ ‫ﻗﺿﯾﺔ‬ ‫أو‬ ‫ﺷﻛوى‬ ‫اﻟﻰ‬ ‫ﺑﺎﺧر‬ ‫أو‬ ‫ﺑﺷﻛل‬ ‫ﺗؤدي‬ ‫ﺣﺎدﺛﺔ‬ ‫أي‬ ‫ﯾﺗﺿﻣن‬ ‫وأﯾﺿﺎ‬
What is the INCIDENT? ‫؟‬ ‫اﻟﺣدث‬ ‫ﻣﺎھو‬
‫ﺗﻔﺎﺻﯾل‬ ‫ﻟﺗوﺛﯾق‬ ‫اﺻداره‬ ‫ﯾﺗم‬ ‫داﺧﻠﻲ‬ ‫ﻓورم‬
‫اﻻﺟراءات‬ ‫واﺗﺧﺎذ‬ ‫ﻓﯾﮫ‬ ‫واﻟﺗﺣﻘﯾق‬ ‫اﻟﺣدث‬
‫اﻟﺻﺣﯾﺣﺔ‬

‫...؟؟‬ ‫اﻻﺑﻼغ‬ ‫ﻟﺘﻘﺎرﻳﺮ‬ ‫ﻧﺤﺘﺎج‬ ‫ﻟﻤﺎذا‬
‫وﻣﻧﻊ‬ ‫اﻟﻣﺧﺎطر‬ ‫ﻟﺗﻘﻠﯾل‬
‫ﺧﻼل‬ ‫ﻣن‬ ‫اﻟﻣﺳﺗﻘﺑﻠﯾﺔ‬ ‫اﻟﺣوادث‬
‫ﺗطوﯾر‬
‫اﻟﻣﻧﺎﺳﺑﺔ‬ ‫اﻟﻌﻣل‬ ‫ﺧطط‬
‫ﻟﺗﺣدﯾد‬ ‫واﻟﻣراﺟﻌﺔ‬ ‫واﻟﺗوﺻﯾﺎت‬
‫اﻟرﻋﺎﯾﺔ‬ ‫ﺟودة‬ ‫ﻟﺗﺣﺳﯾن‬ ‫اﻟﻔرص‬
‫ﺑﺎﻟﻎ‬ ‫أﻣر‬ ‫اﻟﻣوظﻔﯾن‬ ‫ﺳﻼﻣﺔ‬
‫ﻣرة‬ ‫ﺣﺎدث‬ ‫وﻗﻊ‬ ‫إذا‬ .‫اﻷھﻣﯾﺔ‬
‫ﻣرة‬ ‫ﯾﺣدث‬ ‫أن‬ ‫ﯾﻣﻛن‬ ، ‫واﺣدة‬
‫اﻟﺳﺑب‬ ‫ﺗﺣدﯾد‬ ‫ﯾﺗم‬ ‫ﻟم‬ ‫ﻣﺎ‬ ‫أﺧرى‬
‫وﻣﻌﺎﻟﺟﺗﮫ‬
‫واﻟﻣوظﻔﯾن‬ ‫اﻷطﺑﺎء‬ ‫ﻟﺗﻌﻠﯾم‬
‫اﻟﻣواﻗف‬ ‫ﻣﻊ‬ ‫اﻟﺗﻌﺎﻣل‬ ‫ﻛﯾﻔﯾﺔ‬
‫ﻓﻲ‬ ‫اﻟﺣوادث‬ ‫ﻣن‬ ‫واﻟﺣد‬ ‫ﻟﻣﻧﻊ‬
‫اﻟﻣﺳﺗﻘﺑل‬.
‫ﻟﺣﺎدث‬ ‫ﻓورﯾﺔ‬ ‫إدارة‬ ‫ﺿﻣﺎن‬
‫أوﻟوﯾﺔ‬ ‫وﺗﺣدﯾد‬ , ‫اﻟﻠزوم‬ ‫ﻋﻧد‬
‫ﻣﻧﺎﺳب‬ ‫ﻧﺣو‬ ‫ﻋﻠﻰ‬ ‫ﺣﺎدث‬ ‫ﻛل‬
‫وإدارﺗﮫ‬ ‫ﻓﯾﮫ‬ ‫واﻟﺗﺣﻘﯾق‬ .

‫اﻷﺣداث‬ ‫أﻧواع‬
OMISSION
Failing to do the right thing
‫اﻟﺻﺣﯾﺢ‬ ‫اﻟﺷﺊ‬ ‫ﻋﻣل‬ ‫ﻓﻲ‬ ‫اﻟﻔﺷل‬
COMMISSION
Doing
something
wrong
‫اﻟﺧﺎطﺊ‬ ‫اﻟﺷﺊ‬ ‫ﻋﻣل‬

‫ﻣﺻطﻠﺣﺎت‬
1 2 3 4 5Malpractice
Near Miss
Event
Adverse
Event
Sentinel
Event
‫ﻗﺑل‬ ‫ﻣن‬ ‫ﺗﺻرف‬
‫ﻏﺎﻟﺑﺎ‬ ‫اﻟﻣﮭﻧﺔ‬ ‫ﺻﺎﺣب‬
‫اﻻھﻣﺎل‬ ‫ﻋﻠﻰ‬ ‫ﯾدل‬ ‫ﻣﺎ‬
‫ﻏﯾر‬ ‫اﻻداء‬ ‫او‬
‫ﻟﻠﻌﻣل‬ ‫اﻟﺻﺣﯾﺢ‬
‫ﻋﻧﮫ‬ ‫ﯾﻧﺗﺞ‬ ,‫اﻟﻣطﻠوب‬
‫ﻟﻠﻣرﯾض‬ ‫ﺿرر‬
‫ﻏﯾر‬ ‫ﺳﻠﺑﻲ‬ ‫ﺣدث‬
‫ﻧﺗﯾﺟﺔ‬ ‫ﺣدث‬ ,‫ﻣﺗوﻗﻊ‬
‫ﺻﺣﯾﺣﺔ‬ ‫ﻏﯾر‬ ‫ﻋﻣﻠﯾﺔ‬
‫ﺗﻛون‬ ‫ﻗد‬ ,‫ﻣﺎ‬ ‫ﻋﻼج‬ ‫أو‬
‫ﯾﻣﻛن‬ ‫أو‬ ‫ﺿﺎرة‬
‫.ﺗدارﻛﮭﺎ‬
‫ﻟﮫ‬ ‫ﻣﺧطط‬ ‫ﻏﯾر‬ ‫ﺣدث‬
‫وﻗوع‬ ‫ﻗﺑل‬ ‫اﻛﺗﺷﺎﻓﮫ‬ ‫ﺗم‬
‫ﯾﻛون‬ ‫ﻗد‬ ,‫اﻟﺿرر‬
‫ﻟم‬ ‫أو‬ ‫ﻟﻠﻣرﯾض‬ ‫وﺻل‬
‫.ﯾﺻل‬
‫اﺣداث‬ ‫ﻋﻠﻰ‬ ‫ﻗﺎدر‬
‫ﻣرة‬ ‫ﺗﻛرر‬ ‫اذا‬ ‫ﺿرر‬
‫اﺧرى‬.
‫ﻣﺗوﻗﻊ‬ ‫ﻏﯾر‬ ‫ﺣدث‬
‫اﻟوﻓﺎة‬ ‫إﻟﻰ‬ ‫ﯾؤدي‬
‫ﺧطﯾرة‬ ‫ﺑدﻧﯾﺔ‬ ‫وإﺻﺎﺑﺔ‬

‫اﻷﻣﺛﻠﺔ‬ ‫ﺑﻌض‬
Malpractice
-‫داﺧل‬ ‫اﻟﻌﻣﻠﯾﺔ‬ ‫أدوات‬ ‫ﺗرك‬
‫اﻻﻧﺗﮭﺎء‬ ‫ﺑﻌد‬ ‫اﻟﻣرﯾض‬ ‫ﺟﺳم‬
‫اﻟﻌﻣﻠﯾﺔ‬ ‫.ﻣن‬
-‫ﻏﯾر‬ ‫اﻻدوﯾﺔ‬ ‫ﺟرﻋﺎت‬
‫اﻟﺻﺣﯾﺣﺔ‬
Sentinel Event
‫اﻻﻧﺗﺣﺎر‬
‫اﻟوﻗوع‬
‫اﻻطﻔﺎل‬ ‫اﺧﺗطﺎف‬
‫اﻟﺧطﺄ‬ ‫اﻟﻣﻛﺎن‬ ‫ﻓﻲ‬ ‫اﻟﻌﻣﻠﯾﺎت‬
Near Miss
-‫اﻟﮭﺎﺗف‬ ‫ﺑﺳﻠك‬ ‫اﻟﻣوظف‬ ‫ﺗﻌﺛر‬
‫ﺑطرف‬ ‫ﯾﻣﺳك‬ ‫وﻟﻛﻧﮫ‬ ,‫اﻷرض‬ ‫ﻋﻠﻰ‬
‫.اﻟطﺎوﻟﺔ‬
‫ﻟﻐرﻓﺔ‬ ‫اﻟﺧطﺄ‬ ‫اﻟﻣرﯾض‬ ‫ﯾد-ﺧل‬
,‫اﻟﻌﻣﻠﯾﺔ‬ ‫اﺟراء‬ ‫ﻟﺑدء‬ ‫اﻟﻌﻣﻠﯾﺎت‬
‫ﯾﻌرف‬ ‫اﻟطﺑﯾب‬ ‫أن‬ ‫ﯾﺗﺿﺢ‬ ‫وﻟﻛن‬
‫ﺷﺧﺻﯾﺔ‬ ‫ﻣﻌرﻓﺔ‬ ‫اﻟﻣرﯾض‬
‫اﻟﺧطﺄ‬ ‫اﻟﻣرﯾض‬ ‫أﻧﮫ‬ ‫وﯾﻛﺗﺷف‬
Adverse Event
‫اﻟﻌﻣﻠﯾﺔ‬ ‫ﻣﺎﺑﻌد‬ ‫ﻣﺿﺎﻋﻔﺎت‬
‫اﻟدواﺋﯾﺔ‬ ‫اﻟﺗﻔﺎﻋﻼت‬

✓‫اﻟﻠوم‬ ‫اﻟﻘﺎء‬ ‫ﻋدم‬ ‫ﻋﻠﻰ‬ ‫ﺗﻌﺗﻣد‬ ‫اﻟﺣدوث‬ ‫ﺗﻘﺎرﯾر‬
NO BLAME‫أي‬ ‫ﺿد‬ ‫اﻟﺗﻘرﯾر‬ ‫ﯾﺳﺗﺧدم‬ ‫وﻻ‬ ,
.‫ﻣوظف‬
✓.‫ﺗﺎﻣﺔ‬ ‫ﺑﺳرﯾﺔ‬ ‫ﺗﻌﺎﻣل‬ ‫اﻟﺗﻘﺎﯾر‬ ‫ﺟﻣﯾﻊ‬
✓.‫اﻟﺗﻘرﯾر‬ ‫ﻓﻲ‬ ‫اﻟﻣﻌﻧﯾﯾن‬ ‫اﻷﺷﺧﺎص‬ ‫أﺳﻣﺎء‬ ‫ذﻛر‬ ‫ﻋدم‬
✓‫ﺧﻼل‬ ‫ﯾﺑﻠﻎ‬ ‫أن‬ ‫ﯾﺟب‬ ‫اﻟﺗﻘرﯾر‬24‫ﻣن‬ ‫ﺳﺎﻋﺔ‬
‫ﺧﻼل‬ ‫اﺟراء‬ ‫ﯾﺗﺧذ‬ ‫وأن‬ ‫اﻟﺣدث‬72‫ﺳﺎﻋﺔ‬
✓‫ﺗﻔﺎﺻﯾل‬ ‫ﻋن‬ ‫اﻻﺑﻼغ‬ ‫اﻟﻣوظﻔﯾن‬ ‫ﺟﻣﯾﻊ‬ ‫ﻣﺳؤوﻟﯾﺔ‬
‫ﻧﻘطﺔ‬ ‫ھو‬ ‫ﻓﺎﻟﺗﻘرﯾر‬ , ‫ﺣدوﺛﮭﺎ‬ ‫وﻗت‬ ‫ﻓﻲ‬ ‫اﻻﺣداث‬
. ‫ﺧﺎطﺊ‬ ‫اﺟراء‬ ‫أي‬ ‫ﻟﺗﺻﺣﯾﺢ‬ ‫اﻟﺑداﯾﺔ‬
✓.‫واﺿﺣﺔ‬ ‫وﻟﻐﺔ‬ ‫واﺿﺢ‬ ‫ﺑﺧط‬ ‫اﻟﺗﻘرﯾر‬ ‫ﯾﻛﺗب‬

‫اﻷﺧطﺎء‬ ‫ﺗﺑﻠﯾﻎ‬ ‫ﻧظﺎم‬ ‫ﻣراﺣل‬
OVR stages
‫ﻟﻠﺣدث‬ ‫اﻟﻔورﯾﺔ‬ ‫اﻻﺳﺗﺟﺎﺑﺔ‬
‫اﻻوﻟﻰ‬ ‫اﻟﻣرﺣﻠﺔ‬
‫اﻟﺧطﺄ‬ ‫ﺗﺻﺣﯾﺢ‬
‫اﻟﺛﺎﻧﯾﺔ‬ ‫اﻟﻣرﺣﻠﺔ‬
‫اﻟﻧﻣوذج‬ ‫ﻣلء‬
24 ‫ﺧﻼل‬ ,‫اﻟﺣدث‬ ‫ﺑﻌد‬ ‫ﻣﺑﺎﺷرة‬
‫ﺳﺎﻋﺔ‬
‫اﻟﺛﺎﻟﺛﺔ‬ ‫اﻟﻣرﺣﻠﺔ‬
✓‫اﻟﺧطﺄ‬ ‫ﻣن‬ ‫اﻟﺗﻌﻠم‬
✓‫اﻟﺣﻠول‬ ‫ﻓﻌﺎﻟﯾﺔ‬ ‫ﻣﺗﺎﺑﻌﺔ‬
‫اﻟﺳﺎدﺳﺔ‬ ‫اﻟﻣرﺣﻠﺔ‬
‫وﻣﻌرﻓﺔ‬ ‫اﻟﺣدث‬ ‫ﻓﻲ‬ ‫اﻟﺗﺣﻘﯾق‬
‫ووﺿﻊ‬ ‫اﻟﺟذرﯾﺔ‬ ‫اﻷﺳﺑﺎب‬
‫اﻟﺣﻠول‬
‫اﻟﺧﺎﻣﺳﺔ‬ ‫اﻟﻣرﺣﻠﺔ‬
‫ﻣن‬ ‫واﻟﺗﺄﻛد‬ ‫اﻟﻔورم‬ ‫ﻣراﺟﻌﺔ‬
‫ﺳﺎﻋﺔ‬ 72 ‫ﺧﻼل‬ ,‫اﻛﺗﻣﺎﻟﮫ‬
‫اﻟراﺑﻌﺔ‬ ‫اﻟﻣرﺣﻠﺔ‬

‫اﻷﺧطﺎء‬ ‫ﺗﺑﻠﯾﻎ‬ ‫ﻧﻣوذج‬ ‫ﻣلء‬ ‫ﺧطوات‬
1
‫اﻟﺷﺎھد‬
2
3
4
‫اﻟﻣﺷرف‬
‫اﻟﻣدﯾر‬
5
QM
✓‫أو‬ ‫اﻟﻣرﯾض‬ ‫ﺑﯾﺎﻧﺎت‬
‫اﻟﺣدث‬ ‫اﻟﻣﺗﺿررﻣن‬
✓‫اﻟﺣدث‬ ‫ﻣﻌﻠوﻣﺎت‬
‫اﻟﻣﻛﺎن‬ : ‫اﻻﺳﺎﺳﯾﺔ‬
‫واﻟزﻣﺎن‬
Basic Information
‫ﻣن‬ ‫اﻷﺳﺑﺎب‬ ‫ﻣﻌرﻓﺔ‬
‫ﻣن‬ ‫وﻣﻧﻌﮭﺎ‬ ‫اﻟﺟذور‬
‫ﻣﺳﺗﻘﺑﻼ‬ ‫اﻟﺣدوث‬
Prevention
‫ﺣﺳب‬ ‫اﻟﺣدث‬ ‫:ﺗﺻﻧﯾف‬
✓‫اﻟﻣﺻدر‬
✓‫اﻟﻧوع/درﺟﺔ‬
‫اﻟﺿرر‬
Categorization
‫او‬ ‫اﻟﻣدﯾر‬ ‫ﺗﺻرف‬
‫اﻟﺣدث‬ ‫ﻟﺣل‬ ‫اﻟﻣﺷرف‬
Corrective Action
‫ﺑﺷﻛل‬ ‫اﻟﺣدث‬ ‫وﺻف‬
‫ﻣﺑﺳط‬
Description

‫واﻷدوار‬ ‫اﻟﻣﺳؤوﻟﯾﺎت‬
✓‫ﻋﻠﻰ‬ ‫اﻟﻣوظﻔﯾن‬ ‫ﺟﻣﯾﻊ‬ ‫ﺑﺄن‬ ‫اﻟﺗﺄﻛد‬
‫)ﻛﯾﻔﯾﺔ‬ ‫اﻷﺣداث‬ ‫اﺑﻼغ‬ ‫ﺑﻧظﺎم‬ ‫دراﯾﺔ‬
(‫اﻟﺣدث‬ ‫وﻣﻌﺎﻟﺟﺔ‬ ‫اﻻﺑﻼغ‬
✓‫ﻣﻊ‬ ‫ﻟﻠﺣدث‬ ‫اﻟﻔورﯾﺔ‬ ‫اﻟﻣﺗﺎﺑﻌﺔ‬
.‫ﻣﺳﺗﻘﺑﻼ‬ ‫ﺣدوﺛﮫ‬ ‫ﻟﻣﻧﻊ‬ ‫اﻟﺗوﺻﯾﺔ‬
✓‫ﺑﻌد‬ ‫اﻟﺟودة‬ ‫ﻗﺳم‬ ‫اﻟﻰ‬ ‫اﻟﺗﻘرﯾر‬ ‫ارﺳﺎل‬
‫ﻏﺿون‬ ‫)ﻓﻲ‬ ‫اﻛﺗﻣﺎﻟﮫ‬72‫ﺳﺎﻋﺔ‬)
✓‫ﺷﮭد‬ ‫اﻟﻠذي‬ ‫اﻟﻣوظف‬ ‫ﻋﻠﻰ‬
‫اﻟﻣﺷرف‬ ‫ﻓورا‬ ‫ﯾﺑﻠﻎ‬ ‫أن‬ ‫اﻟﺣﺎدﺛﺔ‬
✓‫اﻟﻣدﯾر‬ ‫اﻟﻰ‬ ‫اﻟﺗﻘرﯾر‬ ‫ﯾرﺳل‬ ‫أن‬
‫ﺣﺎﻟﺔ‬ ‫ﻓﻲ‬ ‫اﻟﺟودة‬ ‫/ﻗﺳم‬ ‫اﻟﻣﺑﺎﺷر‬
‫ﺗوﻓره‬ ‫ﻋدم‬
Quality
department
‫وﺳﻼﻣﺔ‬ ‫اﻟﺟودة‬ ‫ﻗﺳم‬
‫اﻟﻣرﺿﻰ‬
Supervisor/Head
/ ‫اﻟﻣﺳؤول‬ ‫اﻟﻣﺷرف‬
‫اﻟﻘﺳم‬ ‫رﺋﯾس‬
Employee
‫اﻟﻣوظﻔﯾن‬
✓‫ﻟزم‬ ‫إذا‬ ‫اﻟﻣوﻗف‬ ‫ﻟﺣل‬ ‫ﺧطوات‬ ‫اﺗﺧﺎذ‬
.‫اﻷﻣر‬
✓‫ﻏﯾر‬ ‫ﻛﺎﻧت‬ ‫اذا‬ ‫ﺳﯾﺎﺳﺎت‬ ‫وﺿﻊ‬
‫ﻣﺗوﻓرة‬
✓‫ﺑطرﯾﻘﺔ‬ ‫اﻟﺗﻘﺎرﯾر‬ ‫اﻛﺗﻣﺎل‬ ‫ﻣﺗﺎﺑﻌﺔ‬
‫ﺻﺣﯾﺣﺔ‬
✓‫رﺑﻊ‬ ‫وﺗﻘرﯾر‬ ‫ﺷﮭري‬ ‫ﻣﻠﺧص‬
.‫اﻟﺗﻘﺎرﯾر‬ ‫ﻋن‬ ‫ﺳﻧوي‬

THANK YOU
‫ﻣﺟرد‬ ‫ﻟﯾﺳت‬ ‫اﻟﺟودة‬
‫ﻋﺎدات‬ ‫ھﻲ‬ .. ‫ﺗﺻرﻓﺎت‬
rahmed@theeyeconsultants.net
0114616161 / 203

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