All patient safety incidents are systematically reported using the appropriate channels
- A patient safety incident is an event or circumstance which could have resulted, or did result, in unnecessary harm to the patient1.
- A patient safety incident that results in harm to the patient is now being called a harmful incident (language which is being proposed to replace adverse event)
- Near misses are also considered patient safety incidents
- 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 death2.
- 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 injury3.
- The majority of patient safety incidents can be avoided, often by taking simple preventative measures4:
- 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
- The individual identifying the incident is usually responsible for initiating an incident report.
- Each facility may lay out its own specific protocols for filing incident reports, including when to make a report and what elements to include within the report.
- It is widely recommended that reports are completed as soon as possible after an incident occurs
- MRTs should be familiar with their local policies with regard to incident reporting and the information required with incident report forms, including what types of incidents their facility requires reporting for
- Reports are based on the factual information available at the time of the incident, which may include5,6:
- Date and time of the incident and its discovery
- Patient details
- People involved in incident
- Type of incident
- Severity of the incident (degree of harm)
- Other pertinent details of the incident
- Care/management following the incident
- Outcome of the event
- An investigation may be carried out in order to learn from the incident5.
- Facts uncovered and decisions made during the investigation may also be included in an incident report
- An incident report goes hand in hand with disclosure following a patient safety incident.
- Disclosure refers to the discussion of incidents with patients and their families
- Incident reporting refers to the formal reporting method used to capture the details of incidents and feed them into local quality control and improvement programs, as well as national and international database efforts
- The required recipients of an incident report will vary by incident type, facility and jurisdiction7.
- MRTs should be familiar with their local requirements for the incident reporting
- A typical system of incident reporting includes contact made with the following individuals/bodies6,8:
- Direct supervisor
- Quality Management Department (if present)
- Other healthcare professionals involved with the incident
- Manufacturers (if applicable)
- National and/or provincial databases (if available)
- The primary purpose of incident reporting is to gather information that can be used to help improve procedures and processes in the future.
- Consistency in terminology and content is helpful if one wishes to compare incidents from across centres, provinces and countries
- The World Health Organization (WHO) is working towards better standards in international terminology surrounding patient safety – called International Classification for Patient Safety (ICPS)9.
- The Canadian Institute for Health Information (CIHI) has adapted their own standards (which deal with incidents related to the use of medications) to align with the ICPS standards.
- For example, the CIHI encourages Canadian users to record degree of harm using the following terms10:
- None: patient outcome is not symptomatic and no treatment is required.
- Mild: patient outcome is symptomatic (mild), loss of function/harm is minimal/intermediate but short term, and no/minimal intervention is required.
- Moderate: patient outcome is symptomatic, requiring intervention, an increased length of stay, or causing permanent or long term harm or loss of function.
- Severe: patient outcome is symptomatic, requiring life-saving or major surgical/medical intervention, shortened life expectancy or major permanent or long term harm or loss of function is caused.
- Death: on balance of probabilities, death was caused or brought forward in the short term by the incident.
Canadian Patient Safety Institute, Canadian Disclosure Guidelines: Being open with patients and families 2011: Available from: http://www.patientsafetyinstitute.ca/en/toolsResources/disclosure/Documents/CPSI%20Canadian%20Disclosure%20Guidelines.pdf#search=Canadian%20Disclosure%20Guidelines%3A%20Being%20open%20with%20patients%20and%20families. [Accessed 29 Nov 2018]
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.
Canadian Institute for Health Information. National System for Incident Reporting, Privacy Impact Assessment, November 2015. Available from: https://www.cihi.ca/sites/default/files/nsir_pia_en_0.pdf. [Accessed 30 Nov 2018]
Alberta Heritage Foundation for Medical Research, Health Technology Assessment Unit. A Reference Guide for Learning from Incidents in Radiation Treatment. Available from: http://www.assembly.ab.ca/lao/library/egovdocs/2006/alhfm/153508.pdf. [Accessed 13 Dec 2018]
Clark BG, Brown RJ, Ploquin JL, et al. The management of radiation treatment error through incident learning. Radiother Oncol 2010;95:344-349.
Thunder Bay Regional Health Sciences Centre. Policy on Safety Reporting for Incidents and Near Misses. Revised 2011.
World Health Organization. International Classification for Patient Safety. Available from: http://www.who.int/patientsafety/implementation/taxonomy/en/. [Accessed 4 Apr 2012]
Ontario Ministry of Health and Long-term Care. Guidelines for Critical Incident Reporting. 2010. Available from: http://www.health.gov.on.ca/en/ms/ecfa/pro/docs/guidelines_cir.pdf. [Accessed 4 Apr 2012]