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    How to organize incident management

    Incident management stands for registering (near) incidents, analyzing which incidents exist within the organization and identifying the causes. Based on these causes, it is necessary to implement improvements together with the healthcare professionals. This is how incident management contributes to better quality and increased patient safety.

    But how do you ensure a successful implementation of incident management? The Patient Safety Company has been assisting organizations around the world to improve their safety and quality for over 15 years now with incident management software. A flexible solution to register and analyze (near) incidents, up to the automation of improvement plans.

    Next, we will discuss the main points concerning the organization of incident management:

    1. Reporting incidents
    2. Options for analyzing incidents
    3. Ensure a safety culture
    4. Internal communication about incidents
    5. (near) incidents as a basis for improvement plans
    6. Setting up a digital incident management system

    Reporting incidents

    At the workplace it is acceptable that sometimes "things don't go quite right". It is not seen as a mistake let alone reported; rather an extra administrative process perceived as being difficult and unnecessary. The error has since been corrected. Why still report it? However, in order to learn from incidents it is important that all incidents are reported.

    Standard forms for reporting incidents, requesting all information required to analyze the incident, make an important contribution to an unambiguous manner of registration. It prevents errors, and it allows for a clear registration. With the TPSC software you have your own online forms: a fast way to record an incident, for example on-site via a cell phone. You can also add photos of the situation to the digital report form.

    We know from calamity studies that these are often caused by a series of events, also known as (near) incidents. When organizations do not look at the (near) incidents, opportunities for improvement remain unused, because they provide a lot of information about the weak links in a process.

    Prompt (near) incident reporting is important, so that everyone involved is still aware of its occurrence. Sometimes a report contains limited information. In order to analyze the incident, it is still necessary to speak to the employee and those directly involved to collect relevant information so that the basic causes can be identified.

    Options for analyzing incidents

    There are various methods to systematically analyze incidents. These can be divided in the system approach and the person approach.

    • The system approach focuses on the layout of the system. The system allows the employee to make a mistake.
    • In the person approach, the conclusion of the analysis is usually that the incident was due to human error.

    Another way of looking at incidents is prospective versus retrospective.

    • A prospective risk analysis helps you understand how systems or processes can fail. This knowledge can be used to anticipate potential errors.
    • A retrospective analysis looks back on what happened. It is a structured approach that leads to identifying basis causes of (near) incidents. PRISMA is an example of a retrospective analysis

    PRISMA has its origins in the chemical process industry and nowadays is also being used in healthcare. The PRISMA analysis examines human, technical and organizational failure factors.

    By centrally registering all the (near) incidents, you will ultimately have enough data to discover trends, such as which type of incidents are more common. This is interesting management information, to be used when deciding which improvements to prioritize.

    Read more about the options for analyzing incidents with our software and its translation into management reports.

    Incident Management overview
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    Ensure a safety culture

    A proactive safety culture contributes to more safety in the workplace. In a safety culture everyone is alert to possible risks. It is also an open atmosphere where everyone actively works on safely reporting incidents and which easily deals with unsafe situations in processes.

    To create a safety culture it is important that employees are aware of unconscious behavior. The following interventions contribute to awareness:

    • conducting audits;
    • doing safety rounds;
    • analyzing and discussing incidents with a team.

    Safety culture ladderThe so-called Safety Ladder can also be used to create awareness. Healthcare organizations can use this instrument to work on increasing employee safety awareness. By setting up, implementing and testing elements that contribute to safe work and safe behavior, the organization can introduce safe behavior into the culture.

    The Safety Ladder can also contribute to assessing the safety culture within an organization. On top of that, it can show what needs to be done to climb the Safety Ladder, or how to improve the safety culture.

    Internal communication about incidents

    Good communication is the foundation of safe work. Many incidents are the result of miscommunication. How can we reduce the chance of miscommunication?

    1. Input questions: when a (near) incident has taken place, all parties involved must be heard in order to come up with a proper assessment for follow-up action. By bundling the insights and experience of multiple colleagues, you get a good idea of the cause and possible areas of improvement.
    2. Share overview of incidents: this method also requires a good reporting module, so that all employees in the organization have direct access to all the information about (near) incidents within a certain department. This way, the organization can share relevant information in a short period of time and also enable other departments to learn from previous mistakes their colleagues made.
    3. Roll out improvement actions throughout the organization: the improvement actions of the departments in question can be adopted by other departments. This not only increases efficiency, but also immediately addresses safety in the workplace. This process would be much more complicated if incidents were kept in a file or on one of the managers’ computers.

    (near) incidents as a basis for improvement plans

    When managers distribute reports, they become aware of the risks within the organization. They are challenged to do things better/differently in their department by making more time, money, people or material available.

    As a result of (near) incidents, management as well as employees can decide to do things differently by adjusting norms, standards or policies. However experience shows that improvement actions are in fact being signaled, but not structurally applied. This is a missed opportunity, because improvement is necessary to achieve strategic goals.

    The TPSC CloudTM application Improve 2.0 is the digital improvement tracking system that registers improvement actions from the whole organization at a central location. It also prioritizes improvement actions, designates managers and monitors lead times. The application automates the improvement process and makes sure that your organization consistently adheres to the Plan-Do-Check-Act cycle.

    PDCA cycle:

    • Plan: establish activities and objectives and how you are going to measure these;
    • Do: implement the plan and possibly experiment with a different approach;
    • Check: check whether the set objectives have been met, evaluate the approach and learn from the new experience that has been gained;
    • Act: adjust your approach based on the new knowledge, so that the set objectives will be met or met with less effort. The objectives may also be adjusted during this phase.
    Digitaal incidenten melden
    What can we learn from digital incident reporting?

    “In order to learn from incidents, it is important that all incidents and near incidents are reported. This blog describes the benefits of digital incident reporting”.

    Second victim na medisch incident
    Healthcare providers as a second victim after incident

    “This blog describes what actions can be taken to better support healthcare professionals who have been involved in a medical incident."

    Incident management blogs:

     

    Setting up a digital incident management system

    A digital incident management system makes it possible for companies to combine all activities related to incidents in one place. So that the organization knows which (near) incidents are taking place, is able to analyze these incidents and use dashboards to inform the rest of the organization. This provides direct tools for tackling the risks in an integrated manner.

    When reporting incidents digitally, you have a good overview of the basic causes of incidents and the types of incidents that occur. The nature and type of the report is automatically registered. By reporting as many (near) incidents as possible, you will set up a valuable database overtime. You can use this database to identify trends, which provide input for an in-depth incident analysis and subsequently contribute to improving safety.

    The automation of processes simultaneously increases effectiveness/productivity. With more attention for automation and safety, your internal processes and the quality of the end product will also improve. Reports on incidents and complaints provide insight into how the processes can be improved.

    Some important functionalities of an incident management system are:

    The registration of an incident
    • option to register different types of incidents, on custom-made forms if necessary;
    • forms can be used at any time or place, be it via the intranet or on-site using a tablet or cell phone;
    • the option to ask colleagues for additional information or to add other information to the file afterwards;
    • option to use an incident and directly create an improvement action
    • user management whereby more options are assigned to the user depending on his/her position;
    Follow-up steps after the incident
    • workflow management for the automation of the right follow-up steps, depending on the type of incident;
    • using status updates and notifications to monitor the handling of reports;
    • various methods to analyze incidents and causes both prospectively and retrospectively;
    • management dashboards & reporting to gain insight into trends and informing the organization about this

    Before purchasing a digital system, it is wise to determine where the need comes from and what you want to achieve with the software. Our patient safety specialists are happy to help. Use our contact form to get in contact

    Overview ready-made applications:

    We have various ready-made applications for incident management. You can quickly start using these applications and adapt them to the specific situation in your organization.

    eBook: How to make the internal business case

    Is your organization about to make the transition from paper to digital work? Or do you have a digital incident management system you want to replace? In both cases the best advice is to make a business case. Download our e-book and use it as a guide for writing your internal business case.

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    Benefits TPSC CloudTM software

    With our software, a complete Quality and Risk Management platform is ready for you.

    1

    Flexible platform

    Access anytime, anywhere, securely managed in the cloud. Flexible and scalable to organize due to the modular structure. With many options to adjust each part to your own needs.

    2

    Easy implementation

    Quick and easy to set up. Due to the user-friendly design, no programming knowledge is required for the implementation. Our consultants are ready to help with your configuration.

    3

    Low cost

    Our software is a cost-efficient solution for quality and risk management, because many of the building blocks have already been made for you! Suitable for both small and large organizations.

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