Transcript Dr Suchita Joshi-Incident reporting

Incident Reporting in Paediatric
Wards: A Pilot study
Dr Suchita Joshi
MBBS, MRCPCh (UK), PhD (UK)
Assistant Professor in Paediatircs
Patan Academy of Health Sciences
What is a critical incident?
‘’A critical incident need not be a dramatic
event: usually it is an incident which has
significance for you. It is often an event which
made you stop and think, or one that raised
questions for you’’.
What is a clinical incident?
• A clinical incident is an event or circumstance
resulting from health care which could have,
or did lead to unintended harm to a person,
loss or damage, and/or a complaint.
• A ‘person’ includes a patient, health care
worker or visitor
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Examples of clinical incidents
Medication
Patient falls
Intended self harm or suicidal behaviour
Therapeutic equipment failure
Environmental hazards
Problems with blood products
Documentation errors
Delayed diagnosis
Hospital acquired infection
Incidents when a patient expresses concern with
their treatment
• Inappropriate treatment/s
Aims of incident reporting
• To improve patient care
• To ensure safety of the patients and the staff
Why did we start reporting incidents?
• To identify hazards
• To learn about safety
• Many incidents happen because of ‘process
failure’
• Many ‘small’ errors lead to a ‘big’ event
• Rarely a ‘person’ failure
To Support a Blame Free Environment
Methods
• Incident reporting form created
• Information regarding when and how to fill
the forms was disseminated to all the medical
and nursing staff
• Emphasized that this is a ‘Blame Free’ process
• Results from the pilot study and action taken
to minimize repetition of incidents was
discussed in presence of medical and nursing
staff
Duration of the pilot study
• 9 months
Location
•NICU
•PICU
•Neonatal nurseries
•Paediatric wards
•OPD
•Labour ward
•ER
Results 1: Incident category
Total incidents reported: 29
• Clinical incidents:21
– Medication error: 11
– Missed diagnosis/
inappropriate treatment: 6
– Blood product transfusion: 2
• Lab error: 1
• Confusion re: which group to
transfuse? : 1
– Equipment failure: 2
• Personal accident: 3
– Needle prick injury: 2
– Fall : 1
• Violence/ Communication
error: 3
• Health: 0
• Others: 2
– Unusual drug reaction: 1
– X-ray : 1
Results 2:
Person affected by the incident
• Patient: 25
• Staff: 4
– Needle prick: 2
– Verbal abuse by the visitor: 1
– Physical attack by the visitor: 1
• Visitor: 0
• Others: 0
Results 4:
Person completing the form
• Nursing staff: 7
• Medical staff: 22
Results 5:
Where did the incident occur?
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NICU 8
PICU 4
Nurseries 5
Children’s ward 8
OPD 2
Labour ward 1
ER 1
Issues discussed
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Security issues
Drug errors
Hospital policy re: needle prick injuries
Precautions to be taken before x-ray
Blood transfusion policy for neonates
How to ensure blood gas solutions do not run out?
Lack of ICU equipment
Missed diagnosis
Ensuring appropriate investigations are sent before blood
transfusion
• Documentation (hypoglycaemia)
• Lab error
Some examples of incidents reported
and action taken
Minimizing drug error
• Formulary for
commonly used drugs
in NICU
• Nursing staff to recheck the drugs before
giving drugs whenever a
new drug cardex is
written or drug dosage
is changed
Transfusion policy for newborns
Donor blood collection for neonatal whole blood
transfusion
• Previous policy:
– Direct collection from donor in a heparinised
syringe
– Problem: clot formation
• Current policy: Use of paediatric blood
collection bags provided by central blood bank
Unusual drug reaction
• Apnea following chloramphenicol injection (4
patients)
• Reported to pharmacy and batch withdrawn
• No further issues
Consenting for lumbar puncture
• Previous policy: Verbal consent
• Current policy: Written informed consent
Making sure that the solution in blood
gas analyzer does not run out
• The ‘traffic light’ signal in the gas machine
highlighted to the residents
• On-call resident to check the signal every day
X-ray taken with electric matress under the baby
Error due to lack of equipment
• Lack of infusion pumps leading to
– Fluid overload and/or hyperglycaemia
– Delay in starting ionotropic drugs, insulin etc
Problems during inter-hospital patient transport
• Use of transfer checklist
Conclusion
• Incident reporting is feasible in our setting too
• It is a good way of learning from our mistakes
without intimidating a single person
• Medication error is the most commonly reported
incident
• Clinical incidents occur more in intensive care
settings
What next?
• To continue reporting the incidents
• Discuss the incidents reported in a regular
basis
• Try to improve quality of care by auditing our
own practice
• To complete the audit cycle to see if incident
reporting has minimized repetition of critical
incidents