The Power of Incident Reporting
Hospitals are very complex and human intensive systems. The quality of patient care is completely dependent on the healthcare workers and is subject to human errors.
Studies show that 1 in every 10 patient is subject to some form of medical error in hospitals. Most of these errors are avoidable and preventable, if a hospital has a system of reporting and a fair and just culture.
An incident may be defined as an occurrence or happening. 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. Some become apparent when a person is harmed, but many such incidents go unnoticed, even when harm is caused to a person.
These incidents may be divided into various categories. The first category is called a “near miss”. It may be defined as an incident which did not reach or affect a patient. For example, a doctor was about to perform a particular procedure on the wrong patient, but was stopped by the nurse before the procedure could be performed. This is called a near miss. This incident did not reach the patient but had a potential of causing harm if the nurse had not stopped the doctor.
The other category is a “no harm” incident. The incident that reached the patient but did not cause any harm may be classified as a no harm incident. For example, a patient was injected a double dose of antibiotic, due to an error in the prescription. However, the patient remained stable and had no adverse reaction. This is a no harm incident.
The third category of incidents is called “adverse event”. Adverse events may be defined as incidents that harm the patients. For example, a patient was being shifted from the stretcher to his bed. During the process he fell accidentally and sustained an injury to his wrist. This incident is classified as an adverse event.
Studies have shown that 90% of incidents in a hospital are “near misses” and only 10% are “adverse events”. If a hospital takes care of the near misses in its settings, those 10% of adverse events can also be prevented. To achieve this, a hospital needs to have a robust system of reporting incidents through which a hospital can record all the near misses and take preventive actions to reduce the potential adverse event.
A major hurdle to this is that the staff usually do not report such incidents because of fear of blame, punishment or humiliation. Hence, a hospital should promote a “no blame” culture.
CARE Hospitals promotes a “no blame” culture and is genuinely interested in improving the safety of its patients, staff and visitors. At all the units, incident reporting forms are available at every nursing station and any incident that has the potential of harming a patient, staff or visitor can be reported.
We have also initiated an online system of incident reporting that can be accessed from CARE family. In this system, staff anonymity is assured as the online form does not require mentioning the name of the individual reporting the incident. It is a simple form that does not take much time to fill.
All the incidents reported across the group are compiled and classified under the common occurring category. In future, the units will be updated on these categories and group-wide policies and training programs developed, based on the feedback.
Through the system of incident reporting, CARE Hospitals aims to improve patient, staff and visitor safety in all the hospitals.
– Dr Rajeev Chourey, VP, Operations & Quality