Characterising the nature of clinical incidents reported across a tertiary health service: a retrospective audit
Brigid M. Gillespie A B F , Wendy Chaboyer A , Rhonda J. Boorman C , Ishtar Sladdin A , Teresa Withers D and Carl de Wet B EA NHMRC Centre of Research Excellence in Wiser Wound Care, Menzies Health Institute Queensland, Griffith University, Parklands Drive, Gold Coast, Qld 4222, Australia. Email: w.chaboyer@griffith.edu.au; i.sladdin@griffith.edu.au
B 1 Hospital Boulevard, Gold Coast University Hospital, Gold Coast Health, Southport, Qld 4215, Australia. Email: Carl.deWet@health.qld.gov.au
C School of Nursing and Midwifery, Griffith University, Parklands Drive, Gold Coast, Qld 4222, Australia. Email: r.boorman@griffith.edu.au
D Neck and Spine Surgery, Gold Coast University Hospital, 1 Hospital Boulevard, Gold Coast University Hospital, Gold Coast Health, Southport, Qld 4215, Australia. Email: Teresa.Withers@health.qld.gov.au
E Health Improvement Unit, Queensland Health, GPO Box 48, Brisbane, 4001, Qld, Australia.
F Corresponding author. Email: b.gillespie@griffith.edu.au
Australian Health Review 45(4) 447-454 https://doi.org/10.1071/AH20271
Submitted: 25 September 2020 Accepted: 8 November 2020 Published: 9 March 2021
Journal Compilation © AHHA 2021 Open Access CC BY-NC-ND
Abstract
Objective Reducing the number of adverse patient safety incidents (PSIs) requires careful monitoring and active management processes. However, there is limited information about the association between hospital settings and the type of PSI. The aims of this study were to describe the severity, nature and characteristics of PSIs from an analysis of their incidence and to assess the relationships between the type of PSI and its setting.
Methods A retrospective audit of a clinical incident management system database was conducted for a tertiary health service in Australia with 620 000 residents. Records of PSIs reported for patients between 1 July 2017 and 30 June 2018 with Safety Assessment Codes (SAC) of PSIs were extracted from the clinical incident management system and analysed using descriptive and inferential statistics. PSIs involving paediatrics, mental health and primary care were excluded.
Results In all, 4385 eligible PSIs were analysed: 24 SAC1, 107 SAC2 and 4254 SAC3 incidents. Across reported PSIs, the most common incidents related to skin injury (28.6%), medication (23.2%), falls (19.9%) and clinical process (8.5%). Falls were reported significantly more often in the medical division (χ2 = 43.85, P < 0.001), whereas skin injury incidents were reported significantly more often in the surgical division (χ2 = 22.56, P < 0.001).
Conclusions A better understanding of the nature of PSIs and where they occur may lead to more targeted quality improvement strategies.
What is known about this topic? Improving patient safety requires effective safety learning systems, which include incident reporting and management processes. Although incident reporting systems typically underestimate the incidence of iatrogenic harm, they do provide valuable opportunities to improve the future safety of health care.
What does this paper add? This study reports the extent and severity of different types of PSIs that typically occur in a large tertiary hospital in Australia. The most common types of incidents are skin injury, falls, medication errors and clinical process. There are empirical associations between the type of PSI and clinical division (medical, surgical).
What are the implications for practitioners? A greater understanding of the types of PSI and the settings in which they occur may inform the development of more targeted quality improvement strategies that potentially reduce their incidence.
References
[1] Canadian Patient Safety Institute. Patient safety incident. 2020. Available at: https://www.patientsafetyinstitute.ca/en/Topic/Pages/Patient-Safety-Incident.aspx [verified 19 June 2020].[2] Clinical Excellence Commission. Clinical Excellence Commission open disclosure handbook. 2014. Available at: http://www.cec.health.nsw.gov.au/Review-incidents/open-disclosure [verified 19 June 2020].
[3] The Joint Commission. Comprehensive accreditation and certification manual for hospitals (E-dition). 2020. Available at: https://e-dition.jcrinc.com/MainContent.aspx [verified 19 June 2020].
[4] Anderson O, Davis R, Hanna G, Vincent C. Surgical adverse events: a systematic review. Am J Surg 2013; 206 253–62.
| Surgical adverse events: a systematic review.Crossref | GoogleScholarGoogle Scholar | 23642651PubMed |
[5] de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008; 17 216–23.
| The incidence and nature of in-hospital adverse events: a systematic review.Crossref | GoogleScholarGoogle Scholar | 18519629PubMed |
[6] Panagioti M, Khan K, Keers RN, Abuzour A, Phipps D, Kontopantelis E, Bower P, Campbell S, Haneef R, Avery AJ, Ashcroft DM. Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis. BMJ 2019; 366 l4185
| Prevalence, severity, and nature of preventable patient harm across medical care settings: systematic review and meta-analysis.Crossref | GoogleScholarGoogle Scholar | 31315828PubMed |
[7] Schwendimann R, Blatter C, Dhaini S, Simon M, Ausserhofer D. The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping review. BMC Health Serv Res 2018; 18 521
| The occurrence, types, consequences and preventability of in-hospital adverse events – a scoping review.Crossref | GoogleScholarGoogle Scholar | 29973258PubMed |
[8] Slawomirski L, Auraaen A, Klazinga N. The economics of patient safety: strengthening a value-based approach to reducing patient harm at national level. Organisation for Economic Co-operation and Development. 2017. Available at: https://www.oecd.org/health/patient-safety.htm [verified 19 June 2020].
[9] Australian Commission on Safety and Quality in Health Care. The state of patient safety and quality in Australian hospitals 2019. 2019. Available at: https://www.safetyandquality.gov.au/publications-and-resources/state-patient-safety-and-quality-australian-hospitals-2019 [verified 19 June 2020].
[10] Sheikh A, Panesar S, Larizgoitia I, Bates D, Donaldson L. Safer primary care for all: a global imperative. Lancet Glob Health 2013; 1 e182–183.
| Safer primary care for all: a global imperative.Crossref | GoogleScholarGoogle Scholar | 25104342PubMed |
[11] World Health Organization. World alliance for patient safety: WHO draft guidelines for adverse events reporting and learning systems: from information to action. 2005. Available at: https://apps.who.int/iris/handle/10665/69797 [verified 19 June 2020].
[12] Bagian JP, Lee C, Gosbee J, DeRosier J, Stalhandske E, Eldridge N, Williams R, Burkhardt M. Developing and deploying a patient safety program in a large health care delivery system: You can’t fix what you don’t know about. Jt Comm J Qual Improv 2001; 27 522–32.
| Developing and deploying a patient safety program in a large health care delivery system: You can’t fix what you don’t know about.Crossref | GoogleScholarGoogle Scholar | 11593886PubMed |
[13] Rafter N, Hickey A, Condell S, Conroy R, O’Connor P, Vaughan D, Williams D. Adverse events in healthcare: learning from mistakes. QJM: IntJ Med 2015; 108 273–7.
| Adverse events in healthcare: learning from mistakes.Crossref | GoogleScholarGoogle Scholar |
[14] Westbrook JI, Li L, Lehnbom EC, Baysari MT, Braithwaite J, Burke R, Conn C, Day RO. What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system. Int J Qual Health Care 2015; 27 1–9.
| What are incident reports telling us? A comparative study at two Australian hospitals of medication errors identified at audit, detected by staff and reported to an incident system.Crossref | GoogleScholarGoogle Scholar | 25583702PubMed |
[15] Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 2004; 13 242–3.
| Analysis of clinical incidents: a window on the system not a search for root causes.Crossref | GoogleScholarGoogle Scholar | 15289620PubMed |
[16] Braithwaite J.. Changing how we think about healthcare improvement. BMJ 2018; 361 k2014–5.
| Changing how we think about healthcare improvement.Crossref | GoogleScholarGoogle Scholar | 29773537PubMed |
[17] Shojania KG, Marang-van de Mheen PJ. Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. BMJ Qual Saf 2020; 29 265–70.
| Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research.Crossref | GoogleScholarGoogle Scholar | 32066571PubMed |
[18] Macrae C. The problem with incident reporting. BMJ Qual Saf 2016; 25 71–5.
| The problem with incident reporting.Crossref | GoogleScholarGoogle Scholar | 26347519PubMed |
[19] Gold Coast Hospital and Health Service. 2018–2019 Annual report. 2019. Available at: https://www.goldcoast.health.qld.gov.au/about-us/publications/annual-report [verified 19 June 2020].
[20] Queensland Health. Hospital performance. 2020. Available at: http://www.performance.health.qld.gov.au/ [verified 19 June 2020].
[21] Vincent C, Taylor-Adams S, Stanhope N. Framework for analysing risk and safety in clinical medicine. BMJ 1998; 316 1154–7.
| Framework for analysing risk and safety in clinical medicine.Crossref | GoogleScholarGoogle Scholar | 9552960PubMed |
[22] National Pressure Injury Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers/injuries: clinical practice guideline. The international guideline. 2019. Available at: https://internationalguideline.com/guideline [verified 19 June 2020].
[23] Bouldin ED, Andresen EM, Dunton NE, Simon M, Waters TM, Liu M, Daniels MJ, Mion LC, Shorr RI. Falls among adult patients hospitalized in the United States: prevalence and trends. J Patient Saf 2013; 9 13–7.
[24] Hitcho EB, Krauss MJ, Birge S, Claiborne Dunagan W, Fischer I, Johnson S, Nast PA, Costantinou E, Fraser VJ. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004; 19 732–9.
| Characteristics and circumstances of falls in a hospital setting: a prospective analysis.Crossref | GoogleScholarGoogle Scholar | 15209586PubMed |
[25] Schwendimann R, Bühler H, De Geest S, Milisen K. Characteristics of hospital inpatient falls across clinical departments. Gerontology 2008; 54 342–8.
| Characteristics of hospital inpatient falls across clinical departments.Crossref | GoogleScholarGoogle Scholar | 18460867PubMed |
[26] Taylor E, Hignett S. The SCOPE of hospital falls: a systematic mixed studies review. Health Environ Res & Design J 2016; 9 86–109.
| The SCOPE of hospital falls: a systematic mixed studies review.Crossref | GoogleScholarGoogle Scholar |
[27] de Wet C. The KM Seedat Lecture: why patient safety incidents predictably occur in family medicine. Transactions 2015; 59 4
[28] Ramirez E, Martin A, Villan Y, Lorente M, Ojeda J, Moro M, Vara C, Avenza M, Domingo MJ, Alonso P, Asensio MJ, Blázquez JA, Hernández R, Frías J, Jesús MD, Frank A. Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital: prospective evaluation through real-time observations of patient safety incidents. Medicine 2018; 97 e12509
| Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital: prospective evaluation through real-time observations of patient safety incidents.Crossref | GoogleScholarGoogle Scholar | 30235764PubMed |
[29] Doherty C, Stavropoulou C. Patients’ willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review. Soc Sci Med 2012; 75 257–63.
| Patients’ willingness and ability to participate actively in the reduction of clinical errors: a systematic literature review.Crossref | GoogleScholarGoogle Scholar | 22541799PubMed |
[30] Gallego B, Magrabi F, Concha OP, Wang Y, Coiera E. Insights into temporal patterns of hospital patient safety from routinely collected electronic data. Health Inf Sci Syst 2015; 3 S2
| Insights into temporal patterns of hospital patient safety from routinely collected electronic data.Crossref | GoogleScholarGoogle Scholar | 25870757PubMed |
