Incident report analysis and follow-up is an integral part of the quality control and safety improvement process
- A large study of adverse events in the Canadian healthcare system found that adverse events occurred in 7.5% percent of all hospitalizations, with 20.8% of these adverse events leading to death1.
- Near misses are even more common. It has been suggested that for every 300 near miss events, there are 29 minor injuries, and one major injury2.
- The majority of patient safety incidents can be avoided, often by taking simple preventative measures3:
- Confirming patient identity
- Reviewing the requisition and/or prescription
- Confirming the procedure or treatment
- Reviewing patient allergies
- Screening for contraindications
- Confirming completion of patient preparation
- Factors that contribute to the occurrence of patient safety incidents and near misses include4:
- Heavy workload and/or staff insufficiencies
- Not following developed policies and procedures
- Taking short cuts
- Near misses and incidents provide information about a system – often revealing flawed underlying structures and processes5.
- A systematic method of capturing information about incidents, including incidents of all severities and near misses, is a key component of organizational risk management and quality improvement processes3,6,7.
- In addition, promoting a just and trusting culture, in which learning from errors is highly prized, helps eliminate the culture of blame and the fear and shame associated with incidents and near misses8.
- The World Health Organization (WHO) has published guidelines on large-scale incident reporting that reflect the importance of an open culture of learning9:
- The fundamental role of patient safety reporting systems is to enhance patient safety by learning from failures of the health-care system
- A culture of blame is not productive and has been shown to hinder the ability to learn from reporting
- Reporting is of value when it leads to a constructive response. At a minimum, this entails feedback of findings from data analysis. Ideally, it also includes recommendations for changes in processes and systems of health care
- Meaningful analysis, learning, and dissemination of lessons learned require expertise and other human and financial resources. The agency that receives reports must be capable of disseminating information, making recommendations for changes, and informing the development of solutions
- Evaluation of incidents and near misses is used to assess whether improvements in the delivery system can be made to reduce the likelihood of similar events occurring in the future.
- Evidence from studies shows that significant reductions have been achieved in centres that take action on their analyses of patient safety incidents10
- Following a patient safety incident or near miss, analysis and corrective action is usually undertaken by a multidisciplinary team10.
- MRTs participate in these activities as required
- MRTs involved with a patient safety incident under investigation may contribute to analysis of the incident
- Investigation teams usually also include managers/team leaders, quality assurance professionals and other healthcare professionals relevant to the process under investigation
- The Canadian Patient Safety Institute (CPSI) model for Root Cause Analysis contains several steps6:
- Gather information
- Initial understanding
- Additional information
- Literature review
- Timeline and final understanding
- Determine contributing factors and root causes
- Formulate causal statements
- Develop actions
- Healthcare organizations can benefit from reporting incidents by generalizing and analyzing similar cases from other institutions9.
- Depending on the incident of interest, the MRT will be able to access a variable amount of information in the scientific literature.
- Information on patient safety incidents related to the administration of medication is readily available by way of the Canadian Medication Incident Reporting and Prevention System.
- Similar systems and databases may be put in place for medical imaging and radiation therapy in the future11.
Baker GR, Norton PG, Flintofft V, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. CMAJ 2004;170(11):1678-1686.
Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS. London: Stationery Office, 2000.
Kohn LT, Corrigan JM, Donaldson MS, eds. To Err is Human: Building a safer health system. Washington DC: National Academy Press; 2000.
Donnelly LF, Dickerson JM, Goodfried MA, Muething SE. Improving patient safety in radiology. Am J Roentgenology 2010;194(5):1183-1187.
Helmreich R. On error management: lessons from aviation. BMJ 2000;320:781-785.
Canadian Patient Safety Institute. Canadian Root Cause Analysis Framework. 2006. Available from: http://www.patientsafetyinstitute.ca/English/toolsResources/rca/Documents/March%202006%20RCA%20Workbook.pdf. [Accessed 4 Apr 2012]
Bogner MS. Operating at the Sharp End: Human Error in Medicine. Hillsdale, NJ: Lawrence Erlbaum Associates, 1994.
Gunderman RB, Burdlick EJ. Error and opportunity. Am J Roentgenology 2007;188(4):901-903.
World Alliance for Patient Safety. WHO Guidelines for Adverse Event Reporting and Learning Systems: From information to action. 2005. Available from: http://www.who.int/patientsafety/events/05/Reporting_Guidelines.pdf. [Accessed 4 Apr 2012]
D’Souza N. Improving Safety and Quality in Radiation Oncology: The Odette Cancer Centre Incident Learning System. Presentation at the 69th CAMRT Annual General Conference, Saskatoon, SK, 2011. Available from: http://www.actrm.ca/professionaldevelopment/conferences/2011/ presentations/06-03%201500%20Improving%20Safety%20and% 20Quality%20in%20Radiation%20Oncology%20-%20Neil%20 D_Souza%20(RT).pdf. [Accessed 4 Apr 2012]
Jones DN, Benveniste KA, Schultz TJ, et al. Establishing national medical imaging incident reporting systems: issues and challenges. J Am Coll Radiol 2010;7(8):582-592.