Incident Reporting

Question 1

What is a Patient safety incident

Answer 1

Patient Safety Incident (PSI) is:
an event or circumstance that could have resulted, or did result in unnecessary harm to a patient

Question 2

PSI can be classified as?

Answer 2

• harmful (adverse events)
• near misses and
• no harm incidents

Question 3

6 Management principles of PSI include?

Answer 3

• Just Culture
• Confidential
• Timely
• Responsive
• Openness about failures
• Emphasis on learning

Question 4

WHO’s Minimum Information Model (MIM) for PSI

Question 5

Objectives of minimum information model

Answer 5

Classification according to:
• Incident identification (Patient information, time, location and agents involved)
• Incident type
• Incident outcomes
• Resulting actions
• Reporter

Question 6

What are the 9 Steps to follow for the management of PSI?

Answer 6

Steps to follow for the management of PSI:
Step 1: Identifying PSIs
Step 2: Immediate action taken
Step 3: Prioritisations
Step 4: Notification
Step 5: Investigation
Step 6: Classification
Step 7: Analysis
Step 8: Implementation of recommendations
Step 9: Learning

Question 7

Step 1

Answer 7

Step 1: Identifying PSIs
○ PSI prevention and or management can only happen if PSIs are detected in time.
○ Although there are different mechanisms that may be used to detect PSIs, most managers get to know about PSIs in their own health establishments from tip-offs, media publications and law-suits or from complaints by patients and members of the public.
○ There are various ways that are used to detect PSIs without the need for additional costs.
○ All PSIs should be reported in one central Patient Safety Incident Management Systems irrespective of the manner in which it was detected/ identified.
○The following are some of the well-known PSI detection methods:
• Patient safety incident reporting by health professionals
• Medical record/retrospective patient record review
• Focus teams
• External sourcesReview of record on follow-up of patients
• Surveys on patients’ experience of careSafety walk rounds
• Use data to identify and guide management of patient safety incidents
• Research studies and findings

Question 8

Ways in which PSI can be identified

Answer 8

Patient safety incident reporting by health professionals
• Inpatient medical record review / retrospective patient
record review
• Focus teams
• External sources
• Review of record on follow-up of patients
• Surveys on patients’ experience of care
• Safety walk rounds
• Use data to identify and guide management of patient
safety incidents
• Research studies and findings

Question 9

Step 2

Answer 9

Actions may include:
• providing immediate care to individuals (patient, staff or visitors) to prevent the harm from becoming worse
• making the situation/scene safe
• gathering basic information from staff while the details are still fresh
• notify South African Police Service (SAP), health establishment’s security or other institution where applicable

Question 10

severity assessment codes (SAC)

Answer 10

3 classes in the Severity Assessment Code
(Annexure E)
• SAC 1 - includes incidents where serious harm or death occurred.
• SAC 2 - includes incidents that caused moderate harm
• SAC 3 - includes incidents that caused minor harm

Question 11

Definition of SAC 1

Answer 11

Serious harm or death that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness

Question 12

Type of event/incident

Answer 12

incident
 Wrong patient or body part resulting in death or
major permanent loss of function
 Retained instruments/other material after surgery
 Wrong surgical procedure
 Surgical site infections that lead to death or
morbidity
 Suicide of a patient in an inpatient unit
 Death or serious morbidity due to assault or injury
 Nosocomial infections resulting in death or
neurological damage
 Blood transfusion that caused serious harm or
death
 Medication error resulting in death of a patient
 Adverse drug reaction (ADR)that results in death
or is life-threatening
 Maternal death or serious morbidity
 Neonatal death or serious morbidity
 Missing/swopped/abscond patient and assisted or
involuntary mental healthcare user/mental ill
prisoner/State patient
 Any other clinical incident which results in serious
harm or death of a patient

Question 13

SAC 2

Answer 13

Moderate harm that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness

Question 14

Type of event/incident SAC 2

Answer 14

Incidents include but are not limited to Moderate harm resulting in:
• Increased length of stay (More than 72 hours to seven days)
• Additional investigations performed
• Referral to another clinician
• Surgical intervention
• Medical intervention
• ADR that resulted in moderate harm
• Blood transfusion reaction

Question 15

SAC 3 type of incident

Answer 15

Incidents include but are not limited to the following:
 Minor harm resulting in increased length of stay of up to 72 hours
 No harm
 Only first aid treatment required
 Near miss that could have resulted in minor harm
 ADR that resulted in minor or no harm
 Blood transfusion reaction that resulted in minor or no harm

Question 16

SAC 3

Answer 16

Minor or no harm that is/could be specifically caused by healthcare
rather than the patient’s underlying condition or illness

Question 17

Step 4

Answer 17

Record keeping
o Patient Safety Incident Reporting Form
o Patient Safety Incident Register
• Incident notification to management – SAC1
Report to next line of management within 24 hours
• Incident notification to patient

Question 18

Step 5

Answer 18

An investigative report should include:
• detailed chronology of circumstances
• summary of the interviews conducted
• root cause analysis that includes the actions to be taken
• conclusions by Patient Safety committee
• recommendations arising from the investigation
Conclude investigation within 60 working days

Question 19

Step 6

Answer 19

A uniform classification system according to the Minimal Information Model as described in section 5.6 ensures accurate data analysis. All PSIs should be classified according to the following classes:
• agents (contributing factors), see annexure A
• incident type, see annexure B
• incident outcome, see annexure C

Question 20

step 6 classification of incident outcome

Answer 20

Patient Organisation
None Property damage
Mild Increase in required resource allocation for
patient
Moderate Media attention
Severe Formal complaint
Death Damaged reputation
Legal ramifications
Othe

Question 21

Step 7

Answer 21

Analysis
Reduce the occurrence of PSIs by analysing the data
o make recommendations
o implement recommendations for change
• Analyse statistical data on (reporting templates):
o data on classifications of agents involved, see
annexure H
o data on classifications of incident type, see annexure I
o data on classifications of incident outcome, see
annexure J
o indicators for PSIs, see annexure K

Question 22

Step 7 indicators

Answer 22

Question 23

Step 7 actions

Answer 23

• Implimantation of recommendations
• Recommendations from the investigations and reviews to be implemented to ensure the development of better systems to ensure improved practices
• The Root Cause Analysis indicates the time frames as well as the staff responsible for implementation – see PSI form

Question 24

Step 9

Answer 24

Learning
Purpose of PSI reporting systems is to
enhance patient safety by learning from
failures of the health-care system
• Reporting can lead to learning and improved
safety through:
o the generation of alerts regarding significant
new hazards,
o feedback and
o analysing reports

Question 25

Step 9

Answer 25

To make an error is human,
to cover up is unforgivable,
but to fail to learn is
inexcusable

Answer 26

Question 27

Classify medical error according to severity

Answer 27

Medical error:
 Serious: potential life threatening harm
 Minor: does not cause harm nor have potential to cause harm
 “Near miss”:

Question 28

2 types of medical error

Answer 28

Preventable
None Preventable

Question 29

Define preventable adverse event

Answer 29

Preventable adverse event: error from error or systems failure

Question 30

Classification of preventable medical error/adverse event

Answer 30

 Type 1: error caused by attending physician
 Type 2: error caused by anyone else in theatre team
 Type 3: systems failure not attributable to an individual

Question 31

Define unpreventable medical error

Answer 31

Unpreventable adverse event: injury or complication not due to error or systems failure, not usually preventable

Question 32

Classify unpreventable error

Answer 32

 Type 1: well known risks associated with high risk therapies
 Type 2: rare but known risks associated with normal treatments. Patient may be unaware of problem

Question 33

Breaking bad news
 4 essential steps:

Answer 33

 Tell the family what happened. Do not speculate.
 Take responsibility for event. Do not assume culpability
 Apologise
 Explain what will be done to prevent future events
 Support of (patient and) family: psychological, social, +- financial
 Do not make personal commitment for financial support (cf Mx)
 Follow-up care. Communication about developments

Question 34

Long-term consequences of adverse even on anaesthetic provider

Answer 34

Defensive, emotionally detached, irritable,
withdrawn.
 Accident prone
 Desensitization: dissociation, disconnect:
burnout
 Substance abuse: alcohol, medication:
addiction
 Suicide

Question 35

Short term consequences of adverse even on anaesthetic provider

Answer 35

Re-living the event: flash backs, nightmares, day dreams
common
 Feeling shock: numb, tired, exhausted, cold.
 Restless, would up: insomnia, irritability, tearfulness
 Doom and gloom: “Everyone hates me, no-one loves me”.
Give up anaesthetics
 Anger and rage: projecting blame
 Guilt and fear: most common and long lasting.
 Withdrawal: ANS imbalance