Incident Reporting Flashcards
What is a Patient safety incident
Patient Safety Incident (PSI) is:
an event or circumstance that could have resulted, or did result in unnecessary harm to a patient
PSI can be classified as?
• harmful (adverse events)
• near misses and
• no harm incidents
6 Management principles of PSI include?
• Just Culture
• Confidential
• Timely
• Responsive
• Openness about failures
• Emphasis on learning
WHO’s Minimum Information Model (MIM) for PSI
Objectives of minimum information model
Classification according to:
• Incident identification (Patient information, time, location and agents involved)
• Incident type
• Incident outcomes
• Resulting actions
• Reporter
What are the 9 Steps to follow for the management of PSI?
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
Step 1
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
Ways in which PSI can be identified
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
Step 2
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
severity assessment codes (SAC)
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
Definition of SAC 1
Serious harm or death that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness
Type of event/incident
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
SAC 2
Moderate harm that is/could be specifically caused by healthcare rather than the patient’s underlying condition or illness
Type of event/incident SAC 2
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
SAC 3 type of incident
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
SAC 3
Minor or no harm that is/could be specifically caused by healthcare
rather than the patient’s underlying condition or illness
Step 4
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
Step 5
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
Step 6
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
step 6 classification of incident outcome
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
Step 7
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
Step 7 indicators
Step 7 actions
• 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
Step 9
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
Step 9
To make an error is human,
to cover up is unforgivable,
but to fail to learn is
inexcusable
Classify medical error according to severity
Medical error:
Serious: potential life threatening harm
Minor: does not cause harm nor have potential to cause harm
“Near miss”:
2 types of medical error
Preventable
None Preventable
Define preventable adverse event
Preventable adverse event: error from error or systems failure
Classification of preventable medical error/adverse event
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
Define unpreventable medical error
Unpreventable adverse event: injury or complication not due to error or systems failure, not usually preventable
Classify unpreventable error
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
Breaking bad news
4 essential steps:
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
Long-term consequences of adverse even on anaesthetic provider
Defensive, emotionally detached, irritable,
withdrawn.
Accident prone
Desensitization: dissociation, disconnect:
burnout
Substance abuse: alcohol, medication:
addiction
Suicide
Short term consequences of adverse even on anaesthetic provider
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
