INCIDENT REPORTING SYSTEM

Incident Reporting
What to report:
 Error: An unintended event or act. This can be something
that was done or something that should have been done but
wasn’t.

 Near Miss: An event that was “caught” and caused no

harm, but for which a recurrence carries a significant chance
of harm.

 Hazardous Condition: Any set of circumstances which

significantly increase the likelihood of a serious adverse
outcome.
• Hospitals use incident reporting systems to monitor
adverse events and other patient safety issues
• Incident reporting systems, which vary in design and
functionality, capture and maintain reports of
patient-safety-related events documented by
physicians, nursing staff, or other hospital staff.
• Reported patient safety events could include adverse
events, “near-misses,” or situations with the
potential to harm patients.
• Incident reports may also include information about
the impact of the event on the patient and the
causes of the events, if known.
• Hospital staff can submit reports in writing or
electronically, depending on the reporting system.
Adverse events happen
• Think about an incident you were involved in

• What happened?

• What was the error?

• What happened next?

 What should happen after an
adverse event?
1. Assessment & treatment of
patient to minimise harm

2. Open disclosure

3. Identification & notification

of the adverse event

4. Review of circumstances &

contributing factors
 Open disclosure = open communication

Open Disclosure refers to open

communication when things go
wrong in health care and include:

1. An expression of regret;

2. A factual explanation of what

happened;

3. Consequences of the event; and

4. Steps being taken to manage the

event and prevent a recurrence.
 Reporting

• Results from a recent

Australian study show when
given a hypothetical situation
involving clinical incidents:

• 90% of interns said they

wouldn’t report

Junior Medical Officers and Medical

Error PMIT 2007
Why doctors may not report
• Feelings of shame or guilt
• Fear of punishment/ retribution
• Membership of profession that values perfection
• System factors
• Inadequate or no feedback
• Time constraints
• Lack of confidentiality
• Failure to respect or have faith in process
• Lack of knowledge on how to report
How does incident reporting lead to improved patient
safety?

Clinical
Incident
System
wide Recognise
corrective Incident
actions

PATIENT EXPERIENCE

Local Notify
Corrective Incident
Actions

Incident
Analysis
 Why report?
Introduction of changes reduce adverse
events by 50 – 75%

• Changes to local protocols

• Audits
• Worksheets & supervised practice
• Feedback & discussion
• Checklists
 “Adverse events: the second victim”

• If you were involved, how did you feel?

• If it wasn’t you, how do you think the doctor felt?

 Complaint Management

 When a grievance, complaint or

concern is received, immediate
resolution at the department
level is attempted.

 If the complaint is not

immediately resolved, contact
the appropriate management
staff for intervention, and enter
the complaint into Feedback.
 Feelings/reactions
In response to their mistakes
doctors said the support they
needed was

•63% someone to talk to

•59% reaffirmation of their

professional competency

•48% validation in theirdecision

making process

•30% reassurance of self worth