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A healthcare incident is an unintended or unexpected event that harmed a patient or caregiver—or has the potential to harm them. Incidents or errors occur for various reasons or root causes, such as system design flaws, lack of administrative oversight, poor training, digression from protocols, miscommunication, and more. Some incidents are preventable, which means there is a multitude of examples of incidents in healthcare that, when properly evaluated, can ultimately contribute to better quality care and help reduce harm.
The statistics are striking: Globally, four in 10 adults have experience with medical errors, either personally or in the care of someone close to them, according to the Institute for Healthcare Improvement. According to the World Health Organization, the occurrence of adverse events due to unsafe care is likely one of the 10 leading causes of death and disability in the world.
Today, there’s a growing understanding that often, multiple system factors cause incidents or errors. As a result, documenting and analyzing them for cause is paramount, providing hospitals and healthcare organizations with valuable lessons about how to improve caregiver and patient safety.
Categories of incidentsMany incidents involving patients and healthcare professionals can be categorized into six groups: 1. Incidents related to administrative issues or planning include:
2. Incidents related to patient examination include:
3. Incidents related to the treatment of the patient include:
4. Incidents related to the dispense of medication include:
5. Incidents related to internal communication include:
6. Incidents related to healthcare workers include:
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Medication-related incidents are the most commonly reported incidents in healthcare. This includes administering the wrong dose, giving medication to the wrong patient, or omitting the dose.
For example, a nurse may scan a medication barcode, get distracted, and then grab the wrong bottle and administer the wrong medication. Or, the wrong dose may be administered because a physician accidentally transposed two numbers when prescribing it. Another example: A patient has a heart attack because they didn’t receive their blood pressure medication on time, due to the emergency department becoming inundated following a mass casualty incident.
Learning why incidents occur can help organizations make improvements to prevent them from happening again. But first, the healthcare system must prioritize incident reporting by providers, staff, and patients. In fact, risk management and patient safety rely on healthcare’s collective:
Even when there is a system in place to log incident reports and follow through on them, and healthcare incidents still occur, it doesn’t necessarily mean that providers are unqualified or have poor intentions. It means there’s room for improvement and opportunities to create a safer healthcare environment for all participants, as in this example:
A hospital’s electronic health record is disabled due to a virus, and no one within the organization can access patient information. The result? Patient treatments are delayed until the issue is investigated and resolved. Analysis of such an incident might lead the organization to create a downtime procedure so all staff knows how to proceed efficiently, should a security breach occur again.
The World Health Organization (WHO) classifies healthcare incidents according to the levels of severity (i.e., mild, moderate, severe, or death) based on the severity of the symptoms or loss of function, the duration of the symptoms, and/or the interventions required as a result of the incident. Organizations may also choose to classify the severity of healthcare incidents based on an increased length of stay as well as the psychological stress associated with a patient-safety incident that can often have a greater impact than any physical harm.
There are also additional types of patient safety incidents identified by the Joint Commission, that some organizations may track:
Incident management refers to the process of analyzing incidents and identifying the causes. Incident management entails more than simply filling out an incident report to track events and prevent them from occurring again. Incident management is also increasingly about handling data for quality improvement that affects reimbursement.
>> Read more about the benefits of a digital system for recording and analyzing incidents.
Cloud technology can help organizations collect and manage data to identify root causes and ultimately improve quality and patient safety. One strategy for increasing all healthcare participants to report incidents is to use a digital incident management system that makes reporting from a smartphone or other device easy.. Read more about this in our eBook Incident Management.
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