02.04.04. Incident reporting in quality improvement
Incident report analysis and follow-up is made an integral part of the quality control and safety improvement process
The importance of learning from incidents and near misses
- Incident reporting, investigation, and learning are core elements of organizational risk management and quality improvement processes.1–4
- Patient safety reporting systems are used to track incident reports. The fundamental purpose of such systems is to enhance patient safety by learning from failures within the healthcare system and enacting positive change.5,6
- An incident is an event or circumstance that could have or did result in unnecessary harm to a patient. Incidents are grouped into one of three categories based on the level of harm7:
- Harmful incidents: A patient safety incident that resulted in harm to the patient.
- No harm incident: A patient safety incident which reached a patient but no discernable harm resulted.
- Near miss: A patient safety incident that did not reach the patient.
- A large study of adverse events in the Canadian healthcare system found patients suffered potentially preventable harm in about 1 in 18 hospitalizations (5.6%) and of the patients who experienced harm, around 20% had more than 1 harmful event in hospital.4
- The incidence of near-miss events has been estimated to be 7 to 100 times more frequent than harm events.8 Near misses and incidents provide information about a system, often revealing opportunities to improve system processes.9,10
- To counter the potential harm of patient safety incidents, programmatic incident learning systems should be used since research has shown they can reduce error, and improve safety and efficiency through standardization.11,12
Reporting culture
- Effective reporting requires an understanding of a just culture, in which programmes recognize the contribution of both system design and its interaction with staff behaviour.2
- A just culture creates a psychologically safe work environment in which to report errors, uses common language to consistently and fairly evaluate behaviour, and places a focus on system design and behavioural choices rather than errors and outcomes.13
- A just culture combined with effective quality improvement tools can result in increased reporting, improved learning, and mitigation of hazards and associated risk factors.2
- Research indicates that there is a trend to under-report patient safety incidents,14 and that near miss event reporting and learning is an underutilized, low-risk opportunity to enhance patient safety.15–17
- In a large review of safety reports, a study showed that patient safety incidents were associated with imaging procedures (54% of reports) and person factors such as communication (71% of reports).18
- 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.5
Learning from incidents in practice
- 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 show that significant reductions in incidents have been achieved in organizations that take action on their analyses of patient safety incidents.19-20
- Following a patient safety incident or near miss, analysis and corrective action is usually undertaken by an interprofessional team.21
- MRTs participate in these activities as required.
- MRTs involved with a patient safety incident under investigation should 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) Incident Analysis Framework contains several steps to performing an analysis of an incident2:
- Understand “What happened”
- Determine “How and why it happened”
- Develop and manage recommended actions “What can be done to reduce the risk of recurrence and make care safer”
- Follow-through with implementing, monitoring and assessing.
- Share what was learned within and outside of the organization.
Incident learning across facilities
- Healthcare organizations can benefit from reporting incidents by generalizing and analyzing similar cases from other institutions.5,22
- MRTs can support competency maintenance by staying informed of changes in patient safety literature and contributing to that literature to support a community of practice.23
- Information on patient safety incidents related to radiation therapy is readily available by way of the National System for Incident Reporting in Radiation Treatment (NSIR-RT) Taxonomy.3
- Similar systems and databases may be put in place for all medical radiation technologies in the future.24
References
- Institute of Medicine (US) Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. (Kohn LT, Corrigan JM, Donaldson MS, eds.). National Academies Press (US); 2000. Accessed August 8, 2020. http://www.ncbi.nlm.nih.gov/books/NBK225182/
- Incident Analysis Collaborating Parties. Canadian Incident Analysis Framework. Canadian Patient Safety Institute; 2012. Accessed August 8, 2020. https://www.patientsafetyinstitute.ca/en/toolsResources/IncidentAnalysis/Documents/Canadian%20Incident%20Analysis%20Framework.PDF
- Milosevic M, Angers C, Liszewski B, et al. The Canadian national system for incident reporting in radiation treatment (NSIR-RT) taxonomy. Pract Radiat Oncol. 2016;6(5):334-341. doi:10.1016/j.prro.2016.01.013
- Canadian Institute for Health Information CPSI. Measuring Patient Harm in Canadian Hospitals. CIHI; 2016:49. Accessed August 27, 2020. https://secure.cihi.ca/free_products/cihi_cpsi_hospital_harm_en.pdf
- World Alliance for Patient Safety. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems: From Information to Action. World Health Organization; 2005. Accessed August 8, 2020. https://jeder-fehler-zaehlt.de/lit/further/Reporting_Guidelines.pdf
- Larizgoitia I, Bouesseau M-C, Kelley E. WHO efforts to promote reporting of adverse events and global learning. J Public Health Res. 2013;2(3). doi:10.4081/jphr.2013.e29
- Disclosure Working Group. Canadian Disclosure Guidelines: Being Open with Patients and Families. Canadian Patient Safety Institute; 2011. Accessed August 7, 2020. https://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf
- Van der Schaaf T, Kanse L. Human error in system design and management. In: Errors and Error Recovery. Vol 253. Lecture Notes in Control and Information Sciences. Springer Verlag; 2000.
- Helmreich RL. On error management: Lessons from aviation. BMJ. 2000;320(7237):781-785. doi:10.1136/bmj.320.7237.781
- Liszewski B. A prioritization framework for the analysis of near misses in radiation oncology. Tech Innov Patient Support Radiat Oncol. 2020;14:36-42. doi:10.1016/j.tipsro.2020.04.001
- Clark BG, Brown RJ, Ploquin JL, Kind AL, Grimard L. The management of radiation treatment error through incident learning. Radiother Oncol. 2010;95(3):344-349. doi:10.1016/j.radonc.2010.03.022
- Kapur A, Goode G, Riehl C, et al. Incident learning and failure-mode-and-effects-analysis guided safety initiatives in radiation medicine. Front Oncol. 2013;3. doi:10.3389/fonc.2013.00305
- Marx D. Patient Safety and the Just Culture. Obstet Gynecol Clin North Am. 2019;46(2):239-245. doi:10.1016/j.ogc.2019.01.003
- Archer S, Hull L, Soukup T, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: A theoretical review of the literature. BMJ Open. 2017;7(12). doi:10.1136/bmjopen-2017-017155
- Hamilton EC, Pham DH, Minzenmayer AN, et al. Are we missing the near misses in the OR?-underreporting of safety incidents in pediatric surgery. J Surg Res. 2018;221:336-342. doi:10.1016/j.jss.2017.08.005
- Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017;43(3):246-254. doi:10.1016/j.jen.2016.10.015
- Kasalak Ö, Yakar D, Dierckx RA, Kwee TC. Patient safety incidents in radiology: frequency and distribution of incident types. Acta Radiol. Published online June 29, 2020:0284185120937386. doi:10.1177/0284185120937386
- Lacson R, Cochon L, Ip I, et al. Classifying safety events related to diagnostic imaging from a safety reporting system using a human factors framework. J Am Coll Radiol JACR. 2019;16(3):282-288. doi:10.1016/j.jacr.2018.10.015
- Flug JA, Ponce LM, Osborn HH, Jokerst CE. Never events in radiology and strategies to reduce preventable serious adverse events. Radiogr Rev Publ Radiol Soc N Am Inc. 2018;38(6):1823-1832. doi:10.1148/rg.2018180036
- Larson DB, Kruskal JB, Krecke KN, Donnelly LF. Key concepts of patient safety in radiology. Radiogr Rev Publ Radiol Soc N Am Inc. 2015;35(6):1677-1693. doi:10.1148/rg.2015140277
- Stavropoulou C, Doherty C, Tosey P. How effective are incident-reporting systems for improving patient safety? A systematic literature review. Milbank Q. 2015;93(4):826-866. doi:10.1111/1468-0009.12166
- Boucaud S, Dorschner D. Patient safety incident reporting: Current trends and gaps within the Canadian health system. Healthc Q. 2016;18(4):66-72. doi:10.12927/hcq.2016.24547 Patient Safety
- Canadian Association of Medical Radiation Technologists. Member code of ethics and professional conduct. CAMRT. Published November 2015. Accessed June 23, 2020. https://www.camrt.ca/mrt-profession/professional-resources/code-of-ethics/
- Jones DN, Benveniste KA, Schultz TJ, Mandel CJ, Runciman WB. Establishing national medical imaging incident reporting systems: Issues and challenges. J Am Coll Radiol. 2010;7(8):582-592. doi:10.1016/j.jacr.2010.03.014
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