This study analyzed 692 adverse events voluntarily reported over 24 months at a private hospital in Sri Lanka. Reporting varied by unit, with the most (26%) from obstetrics and pediatrics. The leading causes of adverse events were non-compliance (15%), surgical site infections (11%), re-admissions (11%), and hospital-acquired infections (11%). Almost all events (98%) caused temporary or no harm. Voluntary reporting was highest for infections and non-compliance. The study concludes voluntary reporting of adverse events is possible in Sri Lankan hospitals.

1. www.postersession.com
Adverse events are unintended injuries
or complications that are caused by
healthcare management rather than by
patients’ underlying conditions [1,2].
Identification and measurement of
these is central to patient safety.
Adverse events occur multiple times
daily in any healthcare system all over
the world.
In general, hospital staff do not report
such events voluntarily commonly due
to inadequate time to write, and fear of
repercussions.
In our passion of improving patient
safety, along with accreditation
obtained from Australian Council of
Healthcare Standards [ACHS] in 2010,
we launched voluntary reporting of
adverse events system.
Objective:
To examine the extent and pattern of
voluntary reporting of adverse events
in the hospital.
Methods
Discussion
Our staff reported 692 adverse
events [28 per month] for 24
months. Reporting varied by unit. It
is encouraging our staff voluntarily
reported events related to non-
compliance and infections related
to care most of the time.
Voluntary reporting of adverse events in an internationally accredited
hospital in Sri Lanka
Samanthi De Silva, Prasantha De Silva, Dorine Samaranayake, HEMAS Hospital, Wattala
2015 June
Bibliography
The number of adverse events reported
each month varied from 10 to 35
[Table 1]. Majority [26%] were from
obstetrics and pediatrics units [Table
2]. The root cause for most adverse
events was non-compliance [15%],
followed by surgical site Infections
[11%], re-admissions [11%], and
hospital acquired infections [11%]
[Table 3]. Almost all events [98%]
belonged to ISR 3 and 4. [Table 4].
Implementation of voluntary reporting
of adverse events is possible in a
private hospital in Sri Lanka.
Introduction
Results
Retrospective analysis of adverse
events reported to the Quality
Department and monthly reviews
conducted at HEMAS Hospital,
Wattala over a period of 24 months
from January 2013 to December 2014
was included in this study.
Severity was rated in a four point
scale from 1-4 at the monthly incident
review meeting according to the
prescribed criteria. While ISR 1 refers
to permanent harm including death,
ISR 2 and 3 means temporary loss of
function and harm sans loss of
function. ISR 4 indicates no harm to
the patient.
Table 1 – Adverse events reporting pattern by month 2013 -2014
0
2
4
6
8
10
12
14
16
18
noncompliance readmission hospital acquired
infeciton
lab incidents occupational
accidents
human errors communication surgical site
infection
Table 2 – Adverse events reporting pattern by unit 2013 - 2014
0
5
10
15
20
25
30
obs and pead units medical units op room ICU ETU OPD
Series 1
0
5
10
15
20
25
30
35
40
45
Table 4 – Reporting of adverse events by ISR severity rating 2013-2014
Conclusion
1.Brennan TA, Leape LL, Laird NM, Hebert L, Localio AR, Lawthers AG, et al.
Incidence of adverse events and negligence in hospitalized patients. Results of the
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2. Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The
Quality in Australian Health Care Study. Med J Aust 1995;163 (9):458-76.
0
20
40
60
80
100
120
140
160
180
200
ISR1 ISR2 ISR3 ISR4
2013
2014
Table 3 – Reporting of adverse events by its type 2013 - 2014