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Incident Report
Ahmad Thanin
Objective
To provide a safe working environment.
Ensure a transparent and structured incident management system.
To improve the quality of patient's treatment.
To evaluate the quality of the services.
To cope with all international and local health standards
Definitions
• is defined as an untoward event which has happened to, or occurred with, a patient(s), staff or visitor(s), the
result of which might be harmful or potentially harmful, or which does cause or lead to injury/harm.
An Incident
• unplanned event that did not result in injury, illness, or damage but had the potential to do so.
Near to Miss:
• Any untoward occurrence which can be unfavorable, and an unintended outcome associated with an
incident.
Adverse Event:
• an object, an unsafe act, an unsafe process, that has the potential to cause harm, loss or damage.
Hazard:
• This can consist of both physical injury and/or mental damage.
Harm:
Sentinel Event definition
Procedures involving the wrong patient or body part resulting in death or major permanent loss of function
Suicide in an inpatient unit
Retained instruments or other material after surgery requiring re-operation or further surgical
procedure.
Intravascular gas embolism resulting in death or neurological damage.
Hemolytic blood transfusion reaction resulting from ABO incompatibility.
Medication error leading to the death of patient reasonably believed to be due to incorrect
administration of drugs.
Maternal death or serious morbidity associated with labor or delivery
Classifications Of Incident Reports
Clinical
Incident.
Equipment
Incident.
Personal
Incident.
Fire
Incident.
Security
Incident.
Violence,
abuse or
Harassment
What should be reported?
Clinical Incident:
all situations
involving the
patient’s safety even
near to miss e.g.
Error Medication
administer.
Falling Down.
Wrong
Documentations.
Any unexpected
treatment outcome
like allergy
Equipment Incident
when the equipment is
involved in an event or
near to miss which had
potential or adverse
outcome. (Software
Problem)
when the equipment not
working due to mechanical
problem or simply
destroyed
• Personal Incident:
Personal Incident
Any incident which
affected an
individual not
directly related to
clinical treatment .
Incident involve
exposure to blood
and body fluids, or
other hazards
associated with
work
• Any incident involving verbal abuse,
unsociable behavior, racial or sexual or
physical assault whether or not injury results.
Fire Incident
Any incident, no
matter how small,
involving fire or
fire warning
system (including
False Alarms) .
Security Incident
Any incident involving
theft, loss or damage
to person or to the
organization’s
property, child
abduction, false
alarms
When should it be reported?
The person who first becomes aware of a
clinical or non-clinical incident or near
miss should report the details using IR
Form.
IR should be filled out as soon as possible
after the incident has occurred and then
forwarded to Quality Office.
All section of the IR must be completed.
IR Process
All staff shall report any incident to their direct supervisor/manger on
appropriate IR Form.
Staff member or being involved as a witness should complete the form
too.
If the clinical incident involve the visitors, a member of nursing team must
escort the person to ER, CN/HN ER should complete the form.
All incidents should be forwarded to quality office for further
investigation and remedial action within 24 hours of incident occurrence.
Quality office will log the incident in the record logbook for investigation.
Incident report file must be maintained by Quality office.
Quality office will conduct and report on frequency analysis.
After investigation, Quality office will suggest for remedial
action in close association with the department
Head/Coordinator and other involved parties.
Quality office will submit monthly report of all incidents to
executive and medical directors, Quality Improvement and
safety committee, Environment of care committee.
Procedures for Managing Incidents
The injured person or damaged property should assessed immediately, to prevent
from further damage or injury and identify emergency or urgent treatment.
A propitiate action or treatment should be taken to minimize the extent of injury or
damage.
For patients error, contact the relevant medical team in order to make quick
assessment of the situation.
Refer as appropriate for medical/other opinion if needed.
Inform the patient relative as soon as possible and start applying the treatment.
In case of Equipment incident
Report and clearly labeled ((DO NOT USE)) until suitable action will performed.
Ensure patient is safe and complete IR.
Keep the device involved in the incident, including the packaging.
Leave all switch and control as they were at the time of incident.
Inform the Biomedic Eng Department for evaluation and repair.
The IR should be completed correctly and fully stating facts and not opinions or suggestions.
Management actions and preventative measures taken must be recorded and fed back to the unit
involved
Improve the Quality control of patient’s treatment.
Improve the strategies aimed at reducing risk for future patients.
Improve overall services.
Improving the policies.
Minimizing any possible future cost.
Improve the Quality control of patient’s treatment.
Improve the strategies aimed at reducing risk for future
patients.
Improve overall services.
Improving the policies.
Minimizing any possible future cost.
7-steps to an effective incident
management process
1- Identification.
2- Notification.
3- Prioritization.
4- Investigation.
5- Classification.
6- Analysis and Action.
7- Feedback .
Elements of an effective incident
report review
Frequency Analysis
Number of reported incidences.
Incident type (event, near miss, …etc)
Action taken / proposed.
Underline causes.
Nature of harm (physical injury, psychological injury, diseases, suffering, disability, death).
Incident cost.
Examples of Reportable clinical and
nonclinical incidents
• wrong diagnosis, incorrect patient
assessment, delay in diagnosis.
• health record not available during
consultation.
• health care associated infection.
• communication problems between a
patient and healthcare professional.
• defective medical device.
General
cases:
Catastrophic Events
Self Harm or Suicide.
infant Abduction or discharged to wrong family.
Rape of a hospitalized patient.
Applying procedures to wrong patients.
Blood transfusion administered to wrong patient.
Blood specimen obtained for cross matching from the wrong patient.
Wrong Blood Group Result.
Risk Incidents
Unexpected Trauma relating to death.
Any unplanned return to OR.
Critical care equipment problems.
infusion pumps problems.
Wrong patient, or wrong site surgery,
Radiology misdiagnosis.
Swab/ instrument count incorrect at the end of
surgery.
Absent medical notes.
Non-Clinical Event
Violence, Abuse.
Risks affects
patient/public safety.
Theft, loss or damage to
personal or
organization’s property
intrusions.
Spills outside of patient
care area.
Incidant report

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Incidant report

  • 2. Objective To provide a safe working environment. Ensure a transparent and structured incident management system. To improve the quality of patient's treatment. To evaluate the quality of the services. To cope with all international and local health standards
  • 3. Definitions • is defined as an untoward event which has happened to, or occurred with, a patient(s), staff or visitor(s), the result of which might be harmful or potentially harmful, or which does cause or lead to injury/harm. An Incident • unplanned event that did not result in injury, illness, or damage but had the potential to do so. Near to Miss: • Any untoward occurrence which can be unfavorable, and an unintended outcome associated with an incident. Adverse Event: • an object, an unsafe act, an unsafe process, that has the potential to cause harm, loss or damage. Hazard: • This can consist of both physical injury and/or mental damage. Harm:
  • 4. Sentinel Event definition Procedures involving the wrong patient or body part resulting in death or major permanent loss of function Suicide in an inpatient unit Retained instruments or other material after surgery requiring re-operation or further surgical procedure. Intravascular gas embolism resulting in death or neurological damage. Hemolytic blood transfusion reaction resulting from ABO incompatibility. Medication error leading to the death of patient reasonably believed to be due to incorrect administration of drugs. Maternal death or serious morbidity associated with labor or delivery
  • 5. Classifications Of Incident Reports Clinical Incident. Equipment Incident. Personal Incident. Fire Incident. Security Incident. Violence, abuse or Harassment
  • 6. What should be reported? Clinical Incident: all situations involving the patient’s safety even near to miss e.g. Error Medication administer. Falling Down. Wrong Documentations. Any unexpected treatment outcome like allergy
  • 7. Equipment Incident when the equipment is involved in an event or near to miss which had potential or adverse outcome. (Software Problem) when the equipment not working due to mechanical problem or simply destroyed
  • 9. Personal Incident Any incident which affected an individual not directly related to clinical treatment . Incident involve exposure to blood and body fluids, or other hazards associated with work
  • 10. • Any incident involving verbal abuse, unsociable behavior, racial or sexual or physical assault whether or not injury results.
  • 11. Fire Incident Any incident, no matter how small, involving fire or fire warning system (including False Alarms) .
  • 12. Security Incident Any incident involving theft, loss or damage to person or to the organization’s property, child abduction, false alarms
  • 13. When should it be reported? The person who first becomes aware of a clinical or non-clinical incident or near miss should report the details using IR Form. IR should be filled out as soon as possible after the incident has occurred and then forwarded to Quality Office. All section of the IR must be completed.
  • 14. IR Process All staff shall report any incident to their direct supervisor/manger on appropriate IR Form. Staff member or being involved as a witness should complete the form too. If the clinical incident involve the visitors, a member of nursing team must escort the person to ER, CN/HN ER should complete the form. All incidents should be forwarded to quality office for further investigation and remedial action within 24 hours of incident occurrence. Quality office will log the incident in the record logbook for investigation.
  • 15. Incident report file must be maintained by Quality office. Quality office will conduct and report on frequency analysis. After investigation, Quality office will suggest for remedial action in close association with the department Head/Coordinator and other involved parties. Quality office will submit monthly report of all incidents to executive and medical directors, Quality Improvement and safety committee, Environment of care committee.
  • 16. Procedures for Managing Incidents The injured person or damaged property should assessed immediately, to prevent from further damage or injury and identify emergency or urgent treatment. A propitiate action or treatment should be taken to minimize the extent of injury or damage. For patients error, contact the relevant medical team in order to make quick assessment of the situation. Refer as appropriate for medical/other opinion if needed. Inform the patient relative as soon as possible and start applying the treatment.
  • 17. In case of Equipment incident Report and clearly labeled ((DO NOT USE)) until suitable action will performed. Ensure patient is safe and complete IR. Keep the device involved in the incident, including the packaging. Leave all switch and control as they were at the time of incident. Inform the Biomedic Eng Department for evaluation and repair. The IR should be completed correctly and fully stating facts and not opinions or suggestions. Management actions and preventative measures taken must be recorded and fed back to the unit involved
  • 18. Improve the Quality control of patient’s treatment. Improve the strategies aimed at reducing risk for future patients. Improve overall services. Improving the policies. Minimizing any possible future cost.
  • 19. Improve the Quality control of patient’s treatment. Improve the strategies aimed at reducing risk for future patients. Improve overall services. Improving the policies. Minimizing any possible future cost.
  • 20. 7-steps to an effective incident management process 1- Identification. 2- Notification. 3- Prioritization. 4- Investigation. 5- Classification. 6- Analysis and Action. 7- Feedback .
  • 21. Elements of an effective incident report review
  • 22. Frequency Analysis Number of reported incidences. Incident type (event, near miss, …etc) Action taken / proposed. Underline causes. Nature of harm (physical injury, psychological injury, diseases, suffering, disability, death). Incident cost.
  • 23. Examples of Reportable clinical and nonclinical incidents • wrong diagnosis, incorrect patient assessment, delay in diagnosis. • health record not available during consultation. • health care associated infection. • communication problems between a patient and healthcare professional. • defective medical device. General cases:
  • 24. Catastrophic Events Self Harm or Suicide. infant Abduction or discharged to wrong family. Rape of a hospitalized patient. Applying procedures to wrong patients. Blood transfusion administered to wrong patient. Blood specimen obtained for cross matching from the wrong patient. Wrong Blood Group Result.
  • 25. Risk Incidents Unexpected Trauma relating to death. Any unplanned return to OR. Critical care equipment problems. infusion pumps problems. Wrong patient, or wrong site surgery, Radiology misdiagnosis. Swab/ instrument count incorrect at the end of surgery. Absent medical notes.
  • 26. Non-Clinical Event Violence, Abuse. Risks affects patient/public safety. Theft, loss or damage to personal or organization’s property intrusions. Spills outside of patient care area.