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Incident Reporting

Incident reporting systems in hospitals aim to identify and reduce patient harm, but underreporting remains a significant issue, capturing less than 10% of adverse events. The document outlines three types of incidents: near misses, adverse events, and sentinel events, along with their definitions and examples. It emphasizes the importance of thorough and honest reporting to improve patient safety and fulfill legal requirements.

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10 views

Incident Reporting

Incident reporting systems in hospitals aim to identify and reduce patient harm, but underreporting remains a significant issue, capturing less than 10% of adverse events. The document outlines three types of incidents: near misses, adverse events, and sentinel events, along with their definitions and examples. It emphasizes the importance of thorough and honest reporting to improve patient safety and fulfill legal requirements.

Uploaded by

dynursgsupdt
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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INCIDENT REPORTING

Ms.PALLAVI KALE
INTRODUCTION
Virtually all hospitals have incident reporting
systems. In fact, although public attention to
patient safety is a recent phenomenon, hospital
reporting systems have existed for more than 40
years. Risk managers developed these systems to
identify injuries that might lead to litigation and
to reduce the number of patients being harmed.
INTRODUCTION-Contd…
Underreporting has previously been recognized as the
major limitation of incident reporting. Of the adverse
events and errors that occur in hospital settings,
reporting systems capture fewer than 10%. Providers
have offered several explanations for failing to report
through the incident reporting system: The time
required, concerns that reports will be used in
performance evaluations or litigation, uncertainty about
what to report, and doubts about whether hospitals use
reports to improve safety.
Murff HJ, Patel VL, Hripcsak G, Bates DW. Detecting adverse events for patient safety research: a review of current
methodologies. J Biomed Inform. 2003;36:131-143. [go to PubMed]
INTRODUCTION-Contd…
Hospitals with particularly strong commitments to
safety use reporting as just one of multiple strategies
for soliciting input from providers about safety hazards,
and integrate incident reporting with other quality
improvement activities. Walk rounds by senior leaders
identify risks that providers have not reported and
convey a commitment to safety.
Gandhi TK, Graydon-Baker E, Huber CN, Whittemore AD, Gustafson M. Closing the loop: follow-up and
feedback in a patient safety program. Jt Comm J Qual Patient Saf. 2005;31:614-621. [go to PubMed]
TYPES OF INCIDENT
There are mainly three types of incidents
● Near Miss
● Adverse Events
● Sentinel Events
NEAR MISS
This is where the incident did not result in harm, loss
or damage, but could have, this is referred to as a ‘Near
Miss’. This may be clinical or non-clinical. Near miss
reporting is just as important in highlighting
weaknesses in systems, policies/procedures and
practices. If near misses are reported and learnt from
and any necessary corrective action taken, they can help
to prevent actual incidents of harm,loss or damage from
occurring..
NEAR MISS EXAMPLE
Consider a patient who is admitted to the hospital and
placed in a shared room. A nurse comes to administer
his medications, but inadvertently gives his pills to the
other patient in the room. The other patient recognizes
that these are not his medications, does not take them,
and alerts the nurse so that the medications can be given
to the correct patient. This situation involved a high
potential for harm, as a cognitively impaired or less
aware patient may have taken the incorrect medications.
ADVERSE EVENT
“Unintended physical injury resulting from or
contributed to by medical care (including the
absence of indicated medical treatment), that
requires additional monitoring, treatment, or
hospitalization, or that results in death."
ADVERSE EVENT-EXAMPLE
A middle-aged man had rectal bleeding. The patient's
physician completed only a limited sigmoidoscopy,
which was negative. The patient had continued rectal
bleeding but was reassured by the physician. Twenty-
two months later, after a 14-kg (30 lb) weight loss, he
was admitted to a hospital for evaluation. He was found
to have colon cancer with metastases to the liver.
ADVERSE EVENT-EXAMPLE

The physicians who reviewed his medical record


judged that proper diagnostic management might have
discovered the cancer when it was still curable. They
attributed the advanced disease to substandard medical
care. The event was considered adverse and due to
negligence."
SENTINEL EVENT
A Sentinel Event is defined by
The Joint Commission (TJC) as any unanticipated
event in a healthcare setting resulting in death or
serious physical or psychological injury to a patient or
patients, not related to the natural course of the
patient's illness.
SENTINEL EVENT-EXAMPLES
An unanticipated death, including, but not limited to,
1. death that is unrelated to the natural course of the
patient’s illness or underlying condition (for
example, death from a postoperative infection or a
hospital-acquired pulmonary embolism);
2. death of a full-term infant; and
3. suicide
SENTINEL EVENT EXAMPLE
major permanent loss of function unrelated to the
patient’s natural course of illness or underlying
condition;
wrong-site, wrong-procedure, wrong-patient surgery;
transmission of a chronic or fatal disease or illness as
a result of infusing blood or blood products or
transplanting contaminated organs or tissues;
infant abduction or an infant sent home with the
wrong parents;
ROOT CAUSE ANALYSIS
Root Cause Analysis’ is a structured investigation
process that aims to assist in the identification or the
root or underlying cause(s) of a particular event or
problem by determining WHY the failure occurred
and the actions necessary to prevent or minimize the
risk of recurrence.
A ROOT CAUSE ANALYSIS WILL BE
CARRIED OUT FOR ANY SITUATION THAT
MEETS SENTINEL EVENT-investigation and
action plan will be completed within 45 days of
identification of the event.
PURPOSE OF INCIDENT
REPORTING
The purpose is to find facts that can lead to corrective
actions, not to find fault. Always look for deeper
causes. Do not simply record the steps of the event.
Reasons to investigate a workplace incident include:
1. most importantly, to find out the cause of incidents
and to prevent similar incidents in the future
PURPOSE OF INCIDENT
REPORTING
2. to fulfill any legal requirements
3. to determine the cost of an incident
4. to determine compliance with applicable regulations
(e.g., occupational health and safety, criminal, etc.)
5. to process workers' compensation claims
WHO HAS TO REPORT?
◦ Employee involved, observed or discovered the
occurrence should complete the Incident Form
◦ Write it on the same day of the incident, because if
you wait a day or two your memory will start to get
a little fuzzy. You should write down the basic facts
you need to remember as soon as the incident
occurs, and submit the report to HOD/immediate
supervisor within 24 hours.
HOW TO WRITE AN INCIDENT
REPORT
1. Provide the basic facts
2. Be thorough. Write as much as you can remember –
the more details, the better.
3. Be accurate. Do not write something in the report that
you aren't sure actually happened.
4. Be clear. Don't use confusing language to describe
what occurred. Your writing should be clear and
concise.
5. Be honest.
SUMMARY
In conclusion, incident reporting systems are nearly
universal in hospitals, and nurses and other hospital
staff already use them routinely, making them natural
tools for improving patient safety today. They are not
without flaws, however. Hospitals could turn incident
reports into modern tools for enhancing patient safety
by, in order of priority: (i) ensuring that frontline
providers learn when reporting has improved safety,
because this motivates providers to report future
events;.
REFERENCES
www.jointcommission.org
https://psnet.ahrq.gov
www.ccohs.ca

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