An- Najah National University Hospital Incident Report
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1 An- Najah National University Hospital Incident Report Quality Management & Patient Safety DepartmentSana yaseen / Quality Admin
2 Remember: No one goes to work intending to make a mistake To Err is humanHuman Error- “We cannot change the human condition, but we can change the conditions under which humans work”.(James Reason BMJ March 2000)Remember: No one goes to work intending to make a mistake
3 To cover up is unforgivable, and to fail to learn is inexcusable.” To err is human,To cover up is unforgivable,and to fail to learn is inexcusable.”Prof Liam Donaldson – WHO Envoy for Patient SafetyAlthough it may be human nature to make mistakes, it also is human nature to:Create solutionsDiscover alternative methodsAnd meet future challenges
4 Important of reporting Learn from mistakesSame mistakes continue to occurPatients continue to be harmed by preventable errorsA Solution = Reporting
5 Why to use Incident Report In the UK National Health Service (NHS) it is believed that a serious adverse event or critical incident occurs inup to 10% of all hospital admissions.That amounts to about 850,000 adverse events per yearand costs the NHS 2 billions of pounds every year in increased hospital costs, treatments and litigation.The World Health Organization (WHO) estimate that, worldwide, 20–40% of all health care spending is wasted due to poor quality care.( NHS Department of Health Report. An Organisation with a Memory. 2000. P49)Why to use Incident Report
6 What is the most common medication error? "A medication error It is the most happening event in the hospitals that may cause or lead to inappropriate medication use .In a study by the U.S. Food and Drug Administration ( FDA ) that evaluated reports of fatal medication errors from 1993 to 1998, the most common error involving medications as related to administration of an improper dose of medicine, accounting for 41% of fatal medication errors.
7 DefinitionsIncident Report ; An internal form which is issued to document the details of the occurrence / event .A sentinel event is an unanticipated occurrence , that reaches a patient and result in any of the following:DeathPermanent harmSever temporary harm: critical, potentially life threatening harm lasting for a limited time with no permanent residual: but requires transfer to a higher level of care/monitoring for a prolonged period of time, or additional major surgery, procedure, or treatment or resolve the condition.
8 Information required on an incident reporting form Patient name and hospital number/date of birthDate and time of incidentLocation of incidentBrief, factual description of incidentName and contact details of any witnessesif any action taken at the timeName and contact details of the person reporting the incident
12 Event Categorization Index National Coordinating Council for Medication Error Reporting and Prevention. Available at: Accessed 05/24/2017.ACircumstance or events that have the capacity to cause errorBAn event/error that did not reach the patientCAn event/error that reached the patient but did not cause harmDAn event/error that reached the patient and required monitoring or investigation to confirm that there is no harm to the patientEAn event/error that contributed to or resulted in temporary harm to the patient required interventionFAn event/error that contributed to or resulted in temporary harm to the patient required in prolonged hospitalizationGAn event/error that contributed to or resulted in permanent patient harmHAn event/error intervention necessary to sustain lifeIAn event/error that contributed to or resulted in patient death
15 Event report policy Based on the event category: All events under categories (G, H, I) should be communicated to the QMO as soon as possible or within one working day.All events under categories (B, C, D, E, F) should be communicated to the departmental/quality performance improvements committees chairperson/director /or manager as soon as possible and within 3 working days for investigation and to set an action plan.The information reported on the event report for is considered confidential.
17 Root Cause Analysis (RCA): Is a process for identifying the basic or contributing causal factors that underline variations in performance associated with sentinel events. to improve performance and reduce risk of recurrence of a serious sentinel event.Those events will be communicated and discussed with the Chief Medical Officer CMO, who will form a root cause analysis committee to investigate the event. in order to develop their action plan for implementation.The root cause analysis (RCA) and action plan is completed within 48 working days of the event or when becoming aware of the event.
18 Decision Tree:Decision Tree: A tool used to guide decision post event investigate their departmental reported events category D to I and recommend actions based on the event investigation decision tree except sentinel events or in cases of an established investigational committees.Guiding questions to the decision tree that should be considered are :Was the harm intentional?Was the individual knowingly impaired?Did the individual consciously decide to engage in an unsafe act?Did the caregiver make a mistake that individuals of similar and training would be likely to make under the same circumstances?Does the individual have a history of unsafe act?
19 Responsibility of The Quality Management Office It’s the responsibility of QMO to review the initial analysis for the event category based on the Event Categorization Index.The Quality Management Office tracks the reports and directs them to the relevant departments and ensures that adequate action is taken with a focus in a culture of safety not to blame the reporter.The QMO will present the event quarterly reports periodically during the Quality Management Council meetingsIt also makes indicators in the number of reported events as mentioned in the event and sentinel policies , to enhance the safety culture and trust relationship between managers and employees.
25 Summary Safety is the goal Incident reporting provides data that helps identify risksSafety is everybody’s businessFocusing in safety culture not to blame the reporter. Sentinel events require a root cause analysis