Critical incident reporting and learning

Abstract

Editor-We were interested to read the article of Professor Mahajan and concur with his view that safety can be improved by learning from incidents and near misses. 1 Furthermore, we agree that investigation of incidents should not underestimate the potential of analysing incidents that are near misses or which have not led to patient harm. 1 We also accept that under-reporting of incidents by doctors can be a significant problem. 2 Whatever the reasons suggested by Mahajan for poor incident reporting, including lack of clarity of what to report, discrimination, and unfamiliarity with reporting systems, they can be overcome relatively easily. 3 We have developed a Portable Digital Assistant-based (PDA-based) incident reporting system for anaesthetists that achieved a 97.5% incident reporting rate with 50% of reports relating to near-miss incidents where no patient harm ensued. 3 The data derived from 14 000 anaesthetics showed that 3.5% will encounter a reportable event. 3 4 The data could also be used to generate comparative reporting rates for organizations, grade of registrar, and time of day (in-hours vs out-of-hours). 4 A second component of the programmed devices included the ability to record and display progress in acquiring competencies in practical procedures such as spinals, epidurals, arterial lines, central lines, etc. 5 Such data demonstrated added value to our organization by proving invaluable in handling a patient complaint. 6 The changes observed in the trainees provided with the devices in our Department of Anaesthesia led us to conclude that we had improved their ethical behaviour by facilitating incident reporting and thus had helped to achieve the highest incident reporting rate in the medical literature. 3 7 Consequently, we would wholeheartedly endorse the comments of Mahajan and hope that future anaesthetists and other clinicians will feel part of the loop and empowered to improve existing systems and patient safety. 1 However, we would add our lessons that incident reporting and logging performance data must be easy (taking ,5 s to complete each task), must occur in a supportive environment, and individual feedback must be made available online. 4 5 8

Clinicians’ perceptions of opioid error–contributing factors in inpatient palliative care services: A qualitative study

“…1,4,20,21 While incident-reporting systems provide some insights into medication error characteristics and potential contributing factors, incident reporting is often skewed towards active failures and rarely considers the latent conditions that caused the error to occur. 17,22 Accordingly, analysis of reported opioid errors in inpatient palliative care services suggests active failures are the major contributing factor to opioid errors in this service type. 23 To fully understand the opioid error contributing factors in inpatient palliative care services and confirm or refute the findings from analysis of incident reports alone, it is essential to explore error contributing factors from the perspective of palliative care clinicians.…”

“…1,4,20,21 While incident-reporting systems provide some insights into medication error characteristics and potential contributing factors, incident reporting is often skewed towards active failures and rarely considers the latent conditions that caused the error to occur. 17,22…”

Can Unified Medical Language System–based semantic representation improve automated identification of patient safety incident reports by type and severity?

“… 2 By retrospectively analyzing incident reports, health systems are striving to detect and manage emerging risks to patient safety. 3 …”

Time‐related changes in post‐operative equine morbidity: A single‐centre study

“…Critical incident reporting and identification of factors influencing post‐operative morbidities have been recognised as essential in human medicine (Smith and Mahajan ; Bolsin et al . ; Tewari and Sinha ) and the recording of post‐operative morbidities is a requirement of the Royal College of Veterinary Surgeons (RCVS ).…”