All patient safety incidents are systematically reported using the appropriate channels
Preventability of patient safety incidents
- An incident is an event or circumstance which could have resulted, or did result, in unnecessary harm to a patient1.
- Harmful incident: A patient safety incident that resulted in harm to the patient. Replaces “adverse event” and “sentinel event”
- 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. Replaces “close call”
- A large study of adverse events in the Canadian healthcare system found that in 2014-2015:
- 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 hospital2
- In addition, near-miss events are much more common than adverse events3.
- The majority of patient safety incidents can be avoided, often by taking simple preventative measures4, including but not limited to:
- 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
Reporting patient safety incidents
- Each facility or organization 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, avoiding subjective commentary.
- 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
- Both incident reporting and disclosure are components of patient safety incident management.
- 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
- Disclosure refers to the discussion of incidents with patients and their families
- A typical system of incident reporting includes contact made with the following individuals/bodies6,7:
- Direct supervisor
- Quality Management Department (if present)
- Other healthcare professionals involved with the incident
- Manufacturers (if applicable)
Work ongoing to standardize classification
- 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)8.
- 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.
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 12 Dec 2019]
Canadian Institute for Health Information and The Canadian Patient Safety Institute. Measuring Patient Harm in Canadian Hospitals. October 2016. Available from: https://secure.cihi.ca/free_products/cihi_cpsi_hospital_harm_en.pdf. [Accessed 12 Dec 2019]
Van der Schaaf TW, Kanse L. Human Error in System Design and Management (Lecture Notes in Control and Information Sciences, 253). In: eds: Elzer PF, Kluwe RH, , Boussoffara B. Errors and Error Recovery. London, England: Springer Verlag. 2000:pg27-38.
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 12 Dec 2019]
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 12 Dec 2019]
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: https://www.who.int/patientsafety/implementation/taxonomy/ICPS-report/en/. [Accessed 12 Dec 2019]