Incidents Reporting in Healthcare

1. Incidents Reporting in Healthcare Rashid Al-AbriMD, FRCS, MBA Senior Consultant, ENT Sultan Qaboos University Hospital

3. Introduction Incident reporting is part of quality improvement and safety The key reason for reporting incidents is to learn from them, and if possible, prevent their repetition.

4. Range of health care errors Sentinel event= Serious incident 10% Harm Minor incident Near miss= Could have caused harm but it did not this time

5. Objectives

6. Objectives • Is to identify and provide information on adverse patient events • Isolate likely human errors and identify anticipatory systems that might prevent errors or mitigate their effects, • Identify faulty systems that might themselves be contributing to diagnostic incidents, and • Suggest improvements to these systems

7. Advantages of IR

8. Advantages of IR • Describe occurrences that are unexpected, unusual, or out of the ordinary routine of a health care facility's operations, whether or not they cause injury; • Provide the basis for a timely and comprehensive investigation of an incident, if necessary; • Provide information with which corrective or remedial action may be planned;

9. Advantages of IR • Provide raw data to identify risk trends for recurring issues and patient safety risks and to institute in-service training; • Provide the information necessary to defend staff members or health care facilities. • Incident reports provide data necessary for examining processes and improving outcomes through appropriate clinical and administrative decision making.

10. What Should be Reported? • All incidents that cause • Injury • Illness • Lost time • Property damage • Environmental damage • Equipment fault

11. When should the incident report be filed? Immediately after the incident occurred - Memories are fresh - Evidence is in place - Immediate corrective actions can be initiated to protect others

12. Who Should Prepare the Report? • Supervisor of the affected employee • Department Administrator • Nurse incharge/ Medical Doctor • Safety committee representative for area • Safety officer • Affected employee(s)

13. Document finding and actions Incident reports usually contain • General information • Description of injury or illness • Description of the incident • Photos or samples • Analysis • Corrective actions • Dates for completion and follow-up

14. 5 Whys ( Report the facts) • What? Describe what happened in detail. • When? Give the date and time of the incident. • Where? Describe the incident's location. • Who? Tell who did what to whom and who witnessed the incident. • Why? Did equipment fail? Did someone fail to perform a certain test?

16. Categorization of IR Sentinel events, eg some deaths, wrong site surgery, incorrect blood transfusion Must be reported within one working day Major Eg. pressure ulcers, medication errors, falls, exposure to infection Must be reported within one- two working days Moderate Incidents that don’t result in harm Must be reported within Two working days Minor

17. Without a detailed analysis of incidents we may fail to uncover problems that are potential hazards to patients and staff.

18. Analysis and Action

19. Follow-Up Ensure that recommended corrective actions • Have been implemented properly • Are effective in eliminating or reducing future incidents • Do not create an unforeseen hazard

20. A PROCESS TO FOLLOW When an event occurs: • R - React positively • E - Evaluate basic (direct) and underlying (root) causes • P - Prevent a recurrence by developing effective controls • O - Opportunity to share the learning that takes place • R - Report Form – User-friendly, uncomplicated report form • T - Trends identification to prevent similar incidents

21. How to improve IR • Education • Reduce fare of reporting • Reduce reporting burden • Improve feedback • Improve IR follow-up and IR closure • Statistical analysis

23. Incidents per Category Jan-Dec 2013 (n= 228)

24. Communication incident Sub-categories (n=50)

25. Damaged Equipment/Furniture/Instrument Incident Sub-categories (n=32)

26. Damaged Medication incident Sub-categories (n=27)

29. Conclusion • The reporting and investigating of all incidents means an opportunity to prevent the incident from recurring. • The Healthcare environment needs to develop a fact finding, blame free atmosphere, positive culture towards the reporting of all incidents.

30. Thank You • “The only sustainable competitive advantage today is the ability to change, adapt, and evolve—and to do it better than the competition.” R Al-Abri 2007, OMJ