Up to 98,000 deaths and 1 million injuries from medical errors are reported in the U.S. each year. These medical errors—also referred to as healthcare incidents or events—are unfortunate and sometimes preventable. As a result, documenting and analyzing them for cause is paramount, providing hospitals and healthcare organizations with valuable lessons about how to improve caregiver and patient safety.
What are healthcare incidents, and what causes them?
A healthcare incident refers to an unintended or unexpected event that harms or has the potential to harm a patient or caregiver. Incidents or errors occur for various reasons or root causes, such as lack of administrative oversight, poor training, digression from protocols, and miscommunication. Some incidents are preventable, which means there are incidents that, when properly evaluated, can contribute to better quality care and help reduce harm.
There’s a growing understanding that often multiple system factors cause incidents or errors. Hospitals are responsible for the systems they design and for their responses to the actions of clinicians, staff, and patients. Meanwhile, individuals are accountable for the choices they make, including reporting incidents and speaking up about systemic problems or failures they see.
What are examples of incidents in healthcare?
One doesn’t need to look far to find examples of healthcare incidents. With healthcare being incredibly complex and fast-paced, it’s easy to make honest mistakes. Here are some examples:
- A physician doesn’t properly wash their hands before suturing a wound. The wound could become infected
- A patient’s breast biopsy results are delayed, leading to a progression of their cancer that could have otherwise potentially been avoided
- A patient is discharged from the hospital prematurely, leading to readmission
- A blood pressure device fails to provide a correct reading, leading to undiagnosed (and untreated) hypertension
- A patient falls due to lack of adequate risk assessment while in the hospital
Hospital caregivers can be harmed as well. A patient may become aggressive, leading to a caregiver injury. Or a caregiver may accidentally stick themselves with a used needle, thus exposing themselves to a patient’s blood.
What are the most commonly reported hospital incidents?
Medication-related incidents are the most commonly reported incidents in healthcare. This includes administering the wrong dose, giving medication to the wrong patient, or omitting the dose.
Take these examples:
- A nurse scans a medication barcode, becomes distracted, and then grabs the wrong bottle and administers the wrong medication
- A physician accidentally transposes two numbers when prescribing a medication, which leads to the wrong dosage
- A patient has a heart attack because they didn’t receive their blood pressure medication on time due to a mass casualty incident inundating the ER
Incidents are insight to patient safety risks
Learning why incidents occur can help organizations make improvements to prevent them from happening again. The healthcare system must prioritize incident reporting by providers, staff, and patients. In fact, risk management and patient safety rely on healthcare’s collective:
- Willingness to report incidents and near-misses
- Ability to learn from mistakes
- Efforts to enact necessary changes
- Enacting safeguards to prevent medical errors and harm
Even when there is a structure in place to log incident reports and follow through on them, healthcare incidents still occur. It doesn’t necessarily mean that providers are unqualified or have poor intentions; it means there’s room for improvement and opportunities to create a safer healthcare environment for all participants.
Are there incident severity levels?
The World Health Organization (WHO) classifies healthcare incidents according to the levels of severity based on the symptoms or loss of function, the duration of symptoms, and/or the interventions required as a result of the incident. Organizations may also choose to classify the severity of healthcare incidents based on an increased length of stay as well as the psychological stress associated with a patient-safety incident that can often have a greater impact than any physical harm.
There are also additional types of patient safety incidents that some organizations may track, such as The Joint Commission’s sentinel events.
What is incident management?
Incident management refers to the process of analyzing incidents and identifying the causes. Incident management entails more than simply filling out an incident report to track events and prevent them from occurring again. Incident management is also increasingly about handling data for quality improvement that affects reimbursement. Organizations can’t improve what they don’t measure, and they can’t measure without comprehensive data and data analytics.
Cloud technology can help organizations collect and manage data to identify root causes and ultimately improve quality and patient safety. One strategy for increasing the number of healthcare participants to report incidents is to use a digital incident management system that makes reporting from a smartphone or other device easy. On the administrative side, there’s a variety of functionality that provides step-by-step guidance through the entire workflow process.
Incident management doesn’t just occur in hospitals, but extends to settings such as outpatient, ambulatory, retail clinics, and care delivered via telemedicine. In short, any healthcare organization is capable of measuring and tracking incidents.
Incident data to improve quality
Preventable harm will continue to occur unless organizations take a proactive approach to mitigate risk. symplr’s patient safety and risk management software is a structured digital event management system that captures (near) incidents, provides analytics, manages workflows, and monitors improvements. Organizations can improve compliance and enhance quality by raising staff awareness of conscious and unconscious behaviors that affect safety, allowing staff and others to report incidents easily, using real-time data to drive process improvement.
Mistakes within complex systems are inevitable—it’s what organizations do with those mistakes that matters.
