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    What type of incidents take place in healthcare

    Jens Hooiveld
    Last modified: 29 April 2021

    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.

    What are healthcare incidents, and what causes them?

    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 incidents

    Many incidents involving patients and healthcare professionals can be categorized into six groups:

    1. Incidents related to administrative issues or planning include:
    • Incorrect agreements and/or conventions
    • Mix-up of patient data in medical records
    • Lack of a resuscitation statement or referral in place
    2. Incidents related to patient examination include:
    • Delayed/incorrect examination results
    • Incorrect examination application
    • Digression from protocols and working agreements
    3. Incidents related to the treatment of the patient include:
    • Contracting an infection (think for example, of COVID-19)
    • Fall incident, eg because the patient falls out of bed or is not mobile enough for a toilet visit
    • Wrong diagnosis and/or incorrect treatment plan
    4. Incidents related to the dispense of medication include:
    • The wrong dose of prescription indicated
    • Wrong medication supplied
    • Incomplete or incorrect medication handoffs
    5. Incidents related to internal communication include:
    • Communication issues regarding the intake, transfer, and discharge of a patient
    • Miscommunication or misunderstanding of orders
    6. Incidents related to healthcare workers include:
    • Needle, cutting, and splashing incidents
    • Aggression by patients or their families


    Examples of incidents in healthcare

    Unfortunately, one doesn’t need to look far to find examples of incidents in healthcare. That’s because the industry is incredibly complex and fast-paced. It’s easy to make honest mistakes.

    1. For example, there could be a mix-up of patient data when two patients have the same first and last names. Or, consider a patient who has an allergy to penicillin. If a provider views the wrong patient—one without any allergies—and then proceeds to administer penicillin to treat the patient’s pneumonia, the patient may have an allergic reaction. Incomplete data and duplicate records contribute greatly to this problem.
    2. Another example of an incident in healthcare could be caused by something as simple as not following established clinical protocols. For example, if a physician doesn’t properly wash their hands before suturing a wound, the wound could become infected.
    3. A patient could develop a decubitus ulcer while in the hospital because the nursing staff didn’t tend to them in a timely manner.
    4. Here’s another example: A patient’s breast biopsy results are delayed or they couldn’t schedule an appointment with their primary care physician in a timely manner, leading to a progression of their cancer that could have otherwise potentially been avoided.
    5. Consider these additional examples of incidents in healthcare: A patient is discharged from the hospital prematurely, leading to readmission. A blood pressure device fails to provide a correct reading, leading to undiagnosed (and untreated) hypertension. A patient falls due to a lack of adequate risk assessment while in the hospital. There are truly too many examples of incidents in healthcare to describe in one article.
    6. Hospital caregivers can be harmed, too. For example, a patient may become aggressive, leading to a caregiver injury. Or a caregiver may accidentally stick themselves with a used needle, thus exposing themselves to a patient’s blood.
    >> Read more about the important issues for the establishment of incident management.

    What is the most commonly reported incident?

    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.

    Incidents give insight into patient safety risks

    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:

    • Willingness to report (near) incidents.
    • Ability to learn from mistakes.
    • Efforts to enact necessary changes.
    • Put safeguards in place to prevent medical errors, injuries, patient safety mishaps, and more.

    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.

    Are there incident severity levels?

    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:

    • Near miss (i.e., a healthcare incident that did not reach the patient or caregiver and therefore did not result in any harm).
    • No-harm incident (i.e., a healthcare incident that did reach the patient or caregiver, but no discernable harm resulted).

    From reporting incidents to incident management

    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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