G195(P) Adverse Events and Datix Incident Reporting in Paediatrics

Abstract

Aims The Francis report (2013) described a failure to listen to patients and staff, a tolerance of clinical risk and a lack of inter-agency communication. Recently, the Datix reporting system has been introduced at our hospital. We aimed to analyse reported incidents and to explore reporting practices in the Paediatric Department. Methods Datix reports submitted between July 2009 and October 2012 were analysed. Staff were subsequently asked to complete an anonymous questionnaire. Results 785 reports were submitted (19.6 per month). The majority involved young children: 32% involved a child under 1 year and 24% involved a child between 1 and 5 years. Most incidents occurred on the General Paediatric ward (59%), followed by the Neonatal Intensive Care Unit (19%) and the Paediatric Emergency Department (18%). 71% of incidents were clinical, 60% of which were medication errors. The majority reported were ‘low’ or ‘medium’ risk, only 4% were ‘high’ risk. A few (13%) led to an adverse outcome, including 12 clinical deteriorations, 6 Emergency Department re-attendances and one recall to hospital. 54 of the 57 questionnaires were returned (95% response rate). Four were incomplete and therefore excluded. Respondents included doctors (42%), nurses (38%), administrative staff (10%), healthcare assistants and play specialists (10%). Perceptions of reporting practices varied: 50% of nurses stated that incidents were always reported but only 5% of doctors said this was the case. Datix data indicated that 70% of reports were submitted by nurses with only 13% being submitted by doctors. Importantly, 60% of participants admitted to never having reported an incident on Datix. Reasons for under-reporting included time pressures, software issues, concerns about anonymity and a perception that reporting was futile. Respondents requested software alterations and training and feedback on the incidents reported. Conclusion Clinical incidents, particularly medication errors, are frequent. Serious incidents are rare. Despite the introduction of the Datix system, there appears to still be significant under-reporting. To reduce medication errors, electronic prescribing has been introduced. Datix training has been incorporated into the Trust induction and junior doctors reporting incidents are routinely asked to complete a Datix form.