Incident reporting
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Pune Adventist Hospital uses incident reports to record and learn from unusual occurrences at the facility. There are three types of incidents that should be reported: near misses within 24 hours, adverse events within 2 hours, and sentinel events immediately. Staff are required to report any incident or accident that causes or has potential to harm. When reporting an incident, the staff member should obtain a form, write an accurate first person account of what happened chronically and factually, and submit it to their department head. The department head will do an initial assessment while the quality team will perform a root cause analysis to prevent future risks and reduce blame.
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Ensuring safety of patients, visitors and staff in hospital premises is the responsibility of the hospital management. However, these three groups are required to have an awareness of their roles and responsibilities to ensure a safe environment.
Needle stick injury
Awareness on needle stick injuries and its prevention plays a major role in safeguarding healthcare professionals.
Medication error
Medication errors are a major concern in the healthcare fraternity. Although unintended, medication errors continue to happen everyday resulting in patient harm.
Initial assessment
Basics of nursing initial assessment needed to be done when a patient is received in the department. Done by the registered nurse, initial assessment is the basis on which further care is planned.
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Incident reporting
- 2. Incident Report • A form used by the hospital management to record the facility’s unusual occurrences.
- 3. Types of Incidents • Near miss • Adverse events • Sentinel events
- 4. Near miss An unplanned event that did not result in injury, illness or damage but had the potential to do so • Also called “close call”
- 5. Near miss • If near misses are reported and learnt from and necessary corrective action is taken, they can help prevent actual incidents of harm, loss or damage. • Near misses should be reported within 24 hours.
- 6. Adverse events • Could have or did lead to unintended harm • It should be reported within 2 hours
- 7. Sentinel events • Related to system or process deficiencies which leads to death or major and enduring loss of function • It should be reported immediately
- 8. Incident reporting (staff) • A requirement to report any incident or accident which has caused or has potential to harm
- 9. How to report an incident • Obtain incident reporting form from your department head • Start the report as soon as possible, the same day if possible. • Write down all basic facts with persons involved
- 10. • Write a first person narrative telling what happened, chronologically • Use full names of people and their actions • Be accurate. Do not write up something you are not sure of • Use short, to the point sentences • Fact oriented • Be honest • Submit to HOD
- 11. Management of the incident • HOD of the incident site should undertake immediate assessment • Root cause analysis (RCA) to be done by the quality team
- 12. Points to remember • The assessment should not be one of blame but of learning and a drive to reduce future risk • The approach of the management following the incident will focus on “what went wrong” and NOT “who went wrong”