· What is GER?
· Creating a GER
· GER – Injury Event
· GER – Witness
· GER – Medication error
· GER – Other event
· GER – General Information
· GER – Notification
· GER – State-specific Information
· GER – Save & Submit
· GER - Worklist
· Reviewing/ Approving/ Following up on GERs
What is GER?
Today I'm going to show you our General Event Report module or GER for short. This module is where you will be doing all of your incident reporting, that you may currently be doing on paper. Anything from an injury, medication error, to a theft, can be reported using this GER section. So let's get started.
Creating a GER
To create a new GER, first click on ‘new’ from the individual tab on your dashboard. Then, select a program and Individual from the lists and the GER form will open up.
What’s very cool about this and Therap, in general, is that a lot of information is going to get pre-filled in for you so you’re not having to waste time. You’ll notice this first box ‘profile info’ is already complete
So next it’s on to the ‘event info’ box. If you need to change the event date you can always do so by clicking on this little calendar.
You can also note if the event occurred somewhere other than the program where you support them. In this next box you can describe anything that was going on before or led up to the event. For example if Mary fell and hurt her knee, but right before that she had been skipping down the hall, and you had verbally cued her to be careful, that’s what you could note in this box. Basically any antecedents or precursors to help you more fully describe the scene and what was going on leading up to the event, if you know.
If the event occurred at the program, all you have to do is check the box ‘same as program address’ and it automatically throws in the address for you. So you haven’t had to type a thing yet.
Next, you need to enter what the event was. So was it an Injury, a Medication Error or any of the other categories shown below?
Documenting an event requires a lot of data to be put in, and the GER entry form has many sections. To make it easier to go back and forth, we have the 'jump to' feature. From here you can quickly jump between sections of the form if you need to make a correction at any time, or have forgotten to add something.
GER – Injury Event
Let’s say it was an injury, we would click on the ‘injury’ button. This will open up a new window with more injury specific information to fill out.
Now you’ll want to fill in as much as you can about what you observed or discovered. Remember that if it’s got a red asterisk, you definitely need to fill it out.
A lot of the information is in little drop down menus, so again, you don’t have to do a lot of typing, just pointing and clicking
The type and cause of injury, whether it was observed or discovered. the time of injury, just remember that the ones marked with the red star are required information for this report to be submitted.
Next, we come down to the body part section. You’ll be able to select up to 3 body parts using the drop down menus or you can click on the ‘body diagram’ button to get a neat visual.
The injury summary section is where you’ll want to fill in all the who, what, where, when, why, how, information about the injury.
You will see at the bottom that you also have the option to add a picture of the injury if you have a digital camera. This is really great for tracking the way an injury looks and also sharing that image with nurses or others who may not be on site to see it firsthand.
When you’re done click ‘add’ at the bottom. Therap is constantly checking your work, which will save you time in the long run, so if you get errors, don’t worry, just fix them. Therap will show you in red what you have missed or inconsistently completed. So instead of having to hand in an incomplete report, and keep getting it back from supervisors to do over, Therap helps you by getting it right the first time around.
Once you’ve hit add, it will load in a blue color onto your GER form.
GER – Witness
You’ll also be able to select up to two witnesses, but this is up to your agency whether it’s require or not. Most places only required witnesses if available for critical incidents. If you select a witness, what will happen is that staff will get a number flagging them on their to do list witness area when they log in, to fill out a witness report. This witness report will then get connected to the GER. You don’t need to put yourself as a witness If you are the one who filling out the GER.
GER – Medication Error
Ok, let’s try adding a medication error. We do this by clicking on the ‘med error’ button and this will open up a new screen with more specific information about the error
First, you’ll need to select the medication error type from the drop down menu. We’ve got a wide array of option, plus there is always the opportunity to select ‘other’ if it does not fall under the listed categories. So, let’s say that staff forgot to give a medication that was ordered. This would be an ‘omission’.
Next you’ll need to put the date that this error was discovered. It automatically puts in today’s date, but if you need to change it, you can always just click on the little calendar and then point and click on whatever date you discovered the omission. Then, right next to the date, you’ll put the time you discovered the error. Remember to put both hours and minutes and select either am or pm.
In the person responsible field, you can note who the med giver was that forgot that med or didn’t give it to the person. If you’re not sure who was responsible you can leave it alone and a supervisor or nurse can always edit this later. Then you can enter the level of se
verity. 1 being very minor and 10 being very severe. For example if that omission caused the person to have to go to the hospital, that would most likely be a 10, or on the high end of severity. Now this next section, is where we really describe the error and the specific med that was omitted. In the ‘as ordered’ section you’re going to fill out what should have been given to the consumer. It will be real easy if your agency has already started using the Medication history section of Therap to document what medication someone is on, because then you can just hit the ‘look up button’. That’ll give you a list of all the medications that are in the system for that Individual, and you would just click ‘add’ to the right of whichever med was ordered, to add it into the GER. If your agency hasn’t started entering medications in the medications history section, or you don’t see the medications you’re looking for, you can always just type it in manually off of the doctor’s order or Medication Administration Record. You will need to enter in the time that the med was supposed to be given, as well Then you’ll hit the button, ‘copy to as given’, which will copy all the information down below, but here you’ll need to delete the dose amount. Since it wasn’t given then there would be no dose amount, or you could even put in a zero. Then you’ll go to the next section, where you’ll verify that the first and last error date, are correct. It automatically puts in today’s date, but if, for example, you omitted that medication for a whole week, you might have to change the first and last dates of error to reflect that. Then you’ll have to put in the total number of errors for this medication. This means that if you forgot to give just one scheduled dose of this medication, than there would be just one error. But, if you had forgotten to give it for 3 consecutive days, there would be 3 errors.
Next you’ll put in the ‘time of the initial error’, so if the medication was supposed to be given at 8am and it wasn’t given at all, then the error was made at 8am when it was supposed to be given
Next you’ll hit the button that says add error, which will load that information down below. You can then continue to add as many other errors as you need by following the same steps that we just did, again. So if a staff person, not only forgot to give one medication, but also forgot all the morning medications, then you would keep adding in the other medication names and ordered information until you got them all in, just like this one.
Next, you’ll fill out the reason for error section. The cause can be selected from the drop down menu, so if staff just didn’t give it, due to human error, than you would probably select staff action/inaction, or if they couldn’t give the med because it was refused by the Individual, then you could put ‘medication refused’
Then you could note any reasons or further explanation for error. Again, if you’re not sure what happened because you were just the one to discover that this occurred then you can only mention what you discovered. You always want to be as objective as possible, so don’t state reasons, if you don’t know.
Next, you’ll need to note if, due to that omission, that consumer needed any medical attention. If they did need attention then you’ll have to specify the date and time that they received it.
Finally, you’ll be able to select up to 2 witnesses, if your agency requires it. This isn’t a required field by Therap, so if there were no witnesses, or your agency or supervisor has said that you don’t need to use that section, then you can skip it, and just go to the bottom of the window and click ‘add'. This will load that Medication error information into the full GER form.
GER – Other Event
It’s very important, that you are all aware of the options under the ‘Other’ button for event types, before selecting something like injury and then getting stuck with not knowing how to classify something that doesn’t fall under the categories listed. It’s going to be much easier for your agency to track events if you are aware of the different options and are sure to use our categories before just creating your own.
So let’s say something other than an injury, med error, restraint, or death happened. To take a look, we would click on the other button, which would open up another window where we can fill out more information about what happened
Under ‘event type’ you’ll see all sorts of possibilities that don’t fall under other areas of the event types. A common one, might be accident, no apparent injury, which you’d use in the example of someone falling down, but not getting any apparent injuries. You can also specify things like a missing consumer, theft, needing to go to the hospital, among others.
You would then put in the event time, whether you observed or discovered it, and any information about the location of where it happened.
The event summary section is the part where you’ll need to type in a narrative of what you observed or discovered, and of course, you’ll want to be as detailed as possible with this.
Finally, just like other event types, you have the option of selecting up to 2 witnesses if you need to, which will prompt that person selected to fill out a specific witness report when they log in to their own account. Ask a supervisor for agency guidelines on whether you need to put witnesses for the event you’re documenting. It’s not required, so if there wasn’t witness beside you, then you can just skip it. Just remember, if you’re the one who was there, you don’t need to put yourself as a witness, because your name is already connected to this report by filling it out. When you’re done you would just hit ‘add’ and it will load this information into the full GER.
GER – General Information
Next you move on to General Information Section and fill out things like whether you suspect abuse or neglect, the notification level and other stuff.
Just remember that creating this GER does not take the place of your normal agency or state guidelines about who you need to call or notify in this type of event. If you are supposed to call someone you should still be following the procedures in addition to documenting that.
Now, I’d like to show you something I know you’ll like – the ‘Jump To’ section. If you quickly want to shuffle back and forth various sections of this form, just click on any of these links. My favorite part of the form is this little, green Help button. You will find it on the right most side of every section on the GER form. Any time you have a question about any field in that section, just click on that button. You will find brief descriptions to guide you along the way.
GER – Notification
You may also see that you get warnings above the add notification info section this warnings are agency specific and are setup by your administrator to give your reminders on who you should be notifying in the case of certain events such as critical events or suspected abuse or neglect. You should then document that you follow these policies right into the notification section.
You’ll be able to add notification info, which is what you do when you call the supervisor, nurse, or anyone you notified about this event. Because if it’s not documented, it didn’t happen.
GER –State-specific Information
Now you will see a section called State Specific Information. This area is something you’ll see if you have a state form that has been added to Therap. If you see this section, you will need to click on the corresponding buttons below to fill out some extra state information.
GER – Save & Submit
Finally, once you’re done, you’ll go down to the bottom and be able to save or submit. You’ll only hit ‘save’ if you’re not done with the document and want to save it as a draft in your worklist. Otherwise, if you’re ready for it to go out to reviewers and approvers, you’ll hit ‘submit’.
Once you hit submit, supervisors, reviewers, nurses, and anyone who needs to see the report will be able to access it.