The statistics are striking: Globally, four in 10 adults have experience with medical errors, either personally or in the care of someone close to them, according to the Institute for Healthcare Improvement. A Centers for Disease Control study found that medical errors are the third leading cause of death in the U.S.
These medical errors—also referred to as healthcare incidents or events—are unfortunate and sometimes tragic. 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 a patient or caregiver—or has the potential to harm them. Incidents or errors occur for various reasons or root causes, such as system design flaws, lack of administrative oversight, poor training, digression from protocols, miscommunication, and more. Some incidents are preventable, which means there are a multitude of examples of incidents in healthcare that, when properly evaluated, can ultimately contribute to better quality care and help reduce harm.
Today, there’s 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 (near) incidents, as well as speaking up about larger systemic problems or failures they see.
Categories of incidents
Many incidents involving patients, providers, and staff fall into four groups:1. Incidents related to administrative issues or planning:
What are examples of incidents in healthcare?
Unfortunately, one doesn’t need to look far to find examples of incidents in healthcare. That’s because the industry is incredibly complex and fast-paced. It’s easy to make honest mistakes. For example:
- There could be a mix-up of patient data when two patients have the same first and last names. Or, consider a patient who has an allergy to penicillin. If a provider views the wrong patient—one without any allergies—and then proceeds to administer penicillin to treat the patient’s pneumonia, the patient may have an allergic reaction. Incomplete data and duplicate records contribute greatly to this problem.
- An incident in healthcare could be caused by something as simple as not following established clinical protocols. For example, if a physician doesn’t properly wash their hands before suturing a wound, the wound could become infected. Or, a patient could develop a decubitus ulcer while in the hospital because nursing staff didn’t tend to them in a timely manner.
- A patient’s breast biopsy results are delayed or they couldn’t schedule an appointment with their primary care physician in a timely manner, leading to a progression of their cancer that could have otherwise potentially been avoided.
- Consider these additional scenarios that introduce room for healthcare incidents: 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. There are truly too many examples of incidents in healthcare to describe in one article.
Hospital caregivers can be harmed, too. For example, 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.
For example, a nurse may scan a medication barcode, get distracted, and then grab the wrong bottle and administer the wrong medication. Or, the wrong dose may be administered because a physician accidentally transposed two numbers when prescribing it. Another example: A patient has a heart attack because they didn’t receive their blood pressure medication on time, due to the emergency department becoming inundated following a mass casualty incident.
Incidents: Insight to patient safety risks
Learning why incidents occur can help organizations make improvements to prevent them from happening again. But first, 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 (near) incidents
- Ability to learn from mistakes
- Efforts to enact necessary changes
- Put safeguards in place to prevent medical errors, injuries, patient safety mishaps, and more
Even when there is a structure in place to log incident reports and follow through on them, and 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, as in these examples:
- A hospital’s electronic health record is disabled due to a virus, and no one within the organization can access patient information. The result? Patient treatments are delayed until the issue is investigated and resolved. Analysis of such an incident might lead the organization to create a downtime procedure so all staff know how to proceed efficiently, should a security breach occur again.
- A long-term care facility’s front desk staff person leaves a paper medical record exposed on their desk where another patient can see it. After the incident occurs, the organization can investigate the cause of the privacy breach and take steps to provide additional HIPAA training, as needed.
Are there incident severity levels?
The World Health Organization (WHO) classifies healthcare incidents according to the levels of severity (i.e., mild, moderate, severe, or death) based on the severity of the symptoms or loss of function, the duration of the 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 identified by The Joint Commission that some organizations may track: Near miss (i.e., a healthcare incident that did not reach the patient or caregiver and therefore did not result in any harm) and a no harm incident (i.e., a healthcare incident that did reach the patient or caregiver, but no discernable harm resulted).
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 all 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.
And 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.
The symplr approach
Preventable harm will continue to occur unless organizations take a proactive approach to mitigate risk. That’s where symplr can help. 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, and using real-time data to drive process improvement.
Mistakes within complex systems are inevitable—it’s what organizations do with those mistakes that matters. Do they ignore them and hope that the mistakes won’t happen again, or do they investigate and examine them so they can ultimately provide safer patient care? Healthcare incidents can be incredible learning opportunities when everyone in the organization commits to a safer environment, embraces incident reporting, and delves into the root causes of medical errors, injuries, and harm.
Are quality and safety part of your team’s daily work within the organization? symplr Patient Safety’s solutions and experts help organizations worldwide to improve their safety and quality protocols.