INTRODUCTION:

One can identify various pitfalls in the practices that we do in our hospitals. A significant number of adverse events occurring during hospitalizations have never given rise to litigation or risk management investigation. It can be due to negligent care, lack of time or lack of feedback. However, the quality assurance efforts at the level of the clinical departments in one hospital can be visualized by the review of risk management records.

Need for a system for reporting:

Human error is inevitable at times, especially in a complex medical system like ours. Errors are maximal in severely sick patients requiring complex treatment in intensive care units.¹ It is impossible to prevent errors. However, if no-one knows what kind of problems are occurring, and how often, it is impossible to design systems which will make health care safer. For example, medication errors are frequent and secondary to transcribing errors, failure to observe correct dose adjustment, and wrong dilution of concentrated drugs for intravenous injection.

Errors will happen in medicine because the system is having some fundamental weakness.² These faults are not only related to medications but also various other aspects. It follows, therefore, that the first, vital, step in improving patient safety is to put in place a completely open system of reporting of all adverse incidents and near misses.³ Mistakes are not common but can be devastating when they occur.⁴

What is an incident?:

An incident is one that can occur through human or mechanical means. The impact of which can be sometimes fatal. An incident may be defined as any activity that has the potential to harm or has already harmed a patient, staff or visitor who may encounter such situations regularly in hospitals. These can be near misses, no harm or adverse events. When an incident, injury or illness has occurred, the system is used to identify the cause, and subsequently address the cause, so that, the same and similar incidents will not reoccur. The concept behind incident reporting system is simple; they provide a mechanism to identify risks so that organizations can implement interventions to reduce these risks.⁵

What things are considered as incidents?:

Purpose of incident reports:

· Helps trigger a rapid response to change any policy or procedure that appears to be a key contributing factor to an incident

· To decide the need for restitution, if personal belongings were lost or damaged

· May be useful in future when dealing with liability issues

What has to be done?:

Prevention is better than cure. Even when no adverse event has occurred, we need to have a system for reporting errors and indiscipline. By reviewing and dissecting out the full sequence of events that led to the incident, one uses a process of Root Cause Analysis to identify how the error occurred and who or what could be responsible.⁶ When things go wrong news spreads fast, and the search to find who is at fault is on. This can all too easily develop into a witch hunt, with the blame game shifting culpability from one person to another. The process of timely response to incidents can be effective but it leaves casualties in its wake, especially when the impact is something worse. People feel threatened, become defensive, have fear of legal penalty, have fear of loss of prestige among colleagues and are unlikely to voluntarily report errors, or adverse events in the future. Thus encourage reporting is the most difficult part, because of the culture of blame which has existed for years, staff members may feel they will be victimized if they report incidents.⁷ An incident form is an administrative document and not a part of the medical record so there is no need to indicate in the patient's chart that an incident form was completed. Moreover, the incident report is considered confidential and cannot be used against the nurse practitioner in a lawsuit.

By and large errors occur because of bad systems and not bad people.⁸ ‘Examine the systems’, it should be the motto as is the practice – what are the possible factors responsible for the incident. Be proactive and try to define the weak points in the system and take appropriate steps, that are a corrective action plan to follow. There is no question of negligence on the part of staff, but patients suffer from our lack of foresight.

Today medicine is highly technology driven. New technologies create new methods for producing errors and constant vigilance is required to track these. Sometimes we are unable to rule out that the system has some faults. Doctors, nurses and technicians working in high risk areas must use anonymous incident reporting, which can acta as a powerful tool.⁹ Lapses of discipline, errors or incidents are noted and dropped into a ‘ballot box’. The head of department opens the box at intervals and uses the reports to generate a discussion on how practices can be improved. Free dialogue is encouraged, no one need feel threatened and a retroactive response to an untoward incident is required. Identify the cause of the incident. Focus on the story, and all the contributory issues, not on the individual. Look for all the underlying causes, not just the ‘final error’ which led to the incident. Include the possibility of understaffing, poor design of systems, poor performance, inadequate skill levels, etc. Come up with an action plan which addresses these – perhaps increasing staffing, improving training, improving systems, or using checklists and other protocols to provide barriers to errors. Look for a long-term result, not a short-term fix.¹⁰ If incidents go unreported, the learning is lost and patients will continue to suffer harm.

Tips for Reporting Incidents:

1. Include essential information, such as identity of the person involved in the incident, the exact time and place of the incident and the name of the doctor you notified.

2. Document any unusual occurrences that you witnessed.

3. Record the events and the consequences for the patient in enough detail that administrators can decide whether or not to investigate further.

4. Write objectively, avoiding opinions, judgments, conclusions, or assumptions about who or what caused the incident. Tell your opinions to your supervisor later.

5. Describe only what you saw and heard and the actions you took to provide care at the scene. Unless you saw a patient fall, write “found patient lying on the floor”.

6. Do not admit that you are at fault or blame someone else. Steer clear of statements like “better staffing would have prevented this incident”.

7. Do not offer suggestions about how to prevent the incident from happening again.

8. Do not include detailed statements from witnesses and descriptions of remedial action; these are normally part of an investigative follow-up.

9. Do not put the report in the medical record. Send it to the person designated to review it according to your facility’s policy.

Reasons for under-reporting of incidents:

Support system for Reporting Incident:

· Allotting time for reporting error

· Easy access to forms and technology

· Integration of error reporting with existing data and technology

· Feedback given directly to reporter and to practice

· Communication occurs regarding changes initiated from error reports

· Support for those involved in making or discovering errors.

CONCLUSION:

It is high time to redesign hospital systems to minimize errors in health care in our country.¹¹ Indian hospitals would do well when learning from others experience and incorporate this concept of incident reporting into our healthcare practice. It will take time for staff members to accept that reporting incidents will not land them in trouble.¹² We need to ensure that all incident reports are auditable and accountable. Completing an incident report is a crucial part of the error notification process, as important as documenting care in a patient's medical record.¹³ Incident reports are the real vehicles that promote reflective learning. Most health care workers will embrace the reporting system when they see visible changes and are made aware that their commitment to safety is valued.¹⁴ Quality is the result of good intention, sincere effort, intelligent thinking, skillful execution and results in rapid advance in health care sector.¹⁵ Patients should never ever suffer from our lack of foresight.

CONFLICT OF INTEREST:

No.

ACKNOWLEDGEMENT:

Mrs. Cicily Joseph.

2. Details of the incident:

Where?
Ward/OPD	ER	OT/Minor OT	Lab/Radiology dept
When?
Date of incident	Time (24hr):
Name of person reporting		Position
To whom reported	When	Position
Family informed (yes/ no)
Witness of incident if any

3. Details of person affected by incident

PATIENT STAFF VISITOR OTHERS
Name of person
Hospital no.	Aadhar card no.	M / F
Date of Birth
Address

4. Description of the incident & action taken at that time:

{Please state facts only, and not opinions. Include details of injuries and treatment.}

5. Factors contributing to this incident.

(Mark main factor with ×)

Medical records unavailable	Verbal aggression
Equipment	Violent behaviour
Electric shock	Sexual harassment
Physical assault	Medication
Hospital acquired infection	Unknown
False alarm	Others (specify)
Falls

6. If medication involved, give details

Name of Drug (BLOCK letters):
Form:	Route:
Dose/strength:
At what stage of the medication process did the incident occur? (Tick all applicable)
Prescribing	Administration
Preparation	Monitoring
Other
Choose medication incident type from list below (tick all applicable)
Adverse drug reaction from indicated use	Contra-indication to use of medicine
Mismatch between patient and medicine	Omitted medicine/ingredient
Patient allergic to medicine	Passed expiry date
Wrong medicine label	Wrong/omitted patient directions
Wrong drug/medicine	Wrong/unclear dose or strength
Wrong frequency	Wrong method or preparation/supply
Wrong quantity	Wrong route
Wrong storage	Other (specify)

7. If Medical Device/Equipment involved, give details

Type of device:
Product Name:	Serial No:
Medical Engineer informed? Yes No

8. 24 Hour Observation Chart

Date	Time	Observation	Name and signature of staff
	(The time of incident)
	(6 hours after incident)
	(12 hours after incident)
	(24 hours after incident)

Signature		Designation
Name		Contact Phone No

FOR OFFICE USE:

Why do you think that this incident occurred? (Contributing factors that led to this incident)

Action or recommendations planned to minimize/ prevent repeat incident (s)

Risk Assessment

Updated or not

Actions Taken

Person Responsible for Change

REFERENCES:

1. F D Daustur. Quality and Safety in Indian Hospitals. JAPI VOL. 56 February 2008, pg: 85-7

2. Volpp KGM, Grande D. Residents suggestions for reducing errors in teaching hospitals. N Engl J Med 2003; 348:851–55.

3. Vincent C. Understanding and responding to adverse events. N Engl J Med 2003; 348:1051–56.

4. Landrigan CP, Parry GJ, Bones CB, et al. Temporal trends in rates of patient harm resulting from medical care. New England Journal of Medicine 2010; 2124-34

5. Renner SW, Hawanitz PJ, Bachner P. Wristband identification error reporting in 712 hospitals. Arch Pathol Lab Med 1993; 117:573–7.

6. Bagian JP. Goshee J. Lee C, et al. The Veterans Affairs root cause analysis system in action. Jt Comm J Qual Improv 2002; 10:531– 45

7. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Critical Care Clinics 2005;21: 1-19.

8. Elden K, Ismai A. The importance of medication errors reporting in improving the quality of clinical care services. Global Journal of Health Sciences 2016 Aug; 8(8): 243–251

9. Graf J. Do you know the frequency of errors in your intensive care unit (Editorial). Crit Care Med 2003; 31:1277–78.

10. Beckmann U, Bohringer C, Carless R. et al Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Critical Care Medicine 2003:1006–1011

11. Pronovost PJ, Thompson DA, Holzmueller CG, et al. Defining and measuring patient safety. Critical Care Clinics 2005;21: 1-19.

12. Kingston MJ, Evans SM, Smith BJ, Berry JG. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust 2004;181: 36-9 [PubMed]

13. Resar RK, Rozich JD, Classen D. Methodology and rationale for the measurement of harm with trigger tools. Qual Saf Health Care 2003;12

14. Braithwaite J, Westbrook M, Travaglia J. Attitudes toward the large-scale implementation of an incident reporting system. Int J Qual Health Care 2008; 20:184-91 [PubMed]

15. Pfeiffer Y, Manser T, Wehner T. Conceptualising barriers to incident reporting: a psychological framework. Qual Saf Health Care 2010; 19: e60 [PubMed]

16. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ 2007;79

17. Braithwaite J, Westbrook M, Travaglia J. Attitudes toward the large-scale implementation of an incident reporting system. International Journal of Quality Health Care 2008; 184-91

18. Tepfers A, Louie H, Drouillard M. Developing an electronic incident report: Experiences of a multi-site teaching hospital. Healthcare Quarterly. 2007;10(2):117–122.

19. Barach P, Small S D. Reporting and preventing medical mishaps: lessons from non‐medical near miss reporting systems. BMJ 2000;759–763

20. Graf J. Do you know the frequency of errors in your intensive care unit (Editorial). Crit Care Med 2003; 31:1277–78.

21. Firth Cozens J. Barriers to incident reporting. Qual Saf Health Care 2002; 11:7.

22. Baker G, Norton P, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004; 170:1678-86.

23. Braithwaite J, Westbrook M, Travaglia J. Attitudes toward the large-scale implementation of an incident reporting system. Int J Qual Health Care. 2008 Jun;20(3):184–19

Received on 18.07.2019 Modified on 23.08.2019

Int. J. of Advances in Nur. Management. 2019; 7(4):347-350.

DOI: 10.5958/2454-2652.2019.00081.7

Please put tick mark for the relevant	Grade	Description	Actual or potential impact
	5	Death	Caused by the incident
	4	Severe Harm	Permanent or long term harm
	3	Moderate Harm	Short term harm- further treatment or procedure required
	2	Low Harm	Minimum harm- extra observation or minor treatment required
	1	No harm	An incident occurred but caused no harm
	0	Near Miss	An incident with the potential to cause harm but which has been prevented and no harm has been caused