INCIDENT REPORTING IN HEALTH CARE – A PROACTIVE APPROACH

Janet Magner

Occupational Health, Safety and Environmental Specialist, Magallan Risk Services

ABOUT THE SPEAKER

Janet is an Occupational Health, Safety and Environmental Specialist with a National Diploma in Safety Management (NADSAM) cum laude in 1995. She has completed many other short training courses with NOSA, attaining the Safety Management Training qualification (SAMTRAC) in 1993. During this year she also completed the Advanced Risk Management course with the Chamber of Mines. In 1998 she completed an Occupational Hygiene – Legislation course with the Pretoria Technikon.

Janet has had more than 10 years experience in Occupational Health, Safety and Environmental Management in both industry and healthcare. She has specialised in the development and implementation of integrated management systems that cover all aspects of Occupational Health, Safety and Environmental risk management. In her capacity as Safety, Health and Environmental Manager for Afrox Limited she was extensively involved in the collation of statistics on incident reporting and analysis of incidents for both the industrial and the health care sections of the corporation. She has been involved in many investigations into the causes of incidents during her career.

Her more recent experiences in development work for projects such as Sustainable Health Care Waste Management in Gauteng and the Solid Waste Management Strategy for Swaziland has given her valuable insight and experience in health care waste management.

Janet is a member of the Waste Management Institute

ABSTRACT

The paper covers the relationship between accidents (consequential incidents) and near misses (non consequential) incidents, discusses previous studies conducted and the many barriers to reporting. It also gives some simple guidelines on the process to follow in setting up an incident reporting structure.

The Health Care industry faces an enormous challenge with the incidence of AIDS and other blood related illnesses on the increase. Exposure to blood borne pathogens by needlestick injuries and spills during the collection and disposal of the health care risk waste affects the staff, patients and general public inside the institution as well as those involved in the collection, transportation, treatment and final disposal of the waste.

Reporting and investigation of incidents is by its very nature a reactive process. The challenge for Health Care Management is to turn this negative phenomenon into a positive opportunity for growth through the culture of learning by mistakes. In other words – Learning from Losses. We can turn the learning into a proactive learning tool approach by reporting and investigating all types of incidents.

There has been a concerted effort over the past few years in America and Europe to make inroads into the area of near miss reporting. Early in 2000 a health care industry-wide CEO-level task force was set up to concentrate efforts into areas other than mandatory reporting which deals with the problem only after it occurs and generally results in blame.

The Healthcare environment needs to develop a positive, blame free culture towards the reporting of all incidents, including those with no consequence (Near Misses). Flawed procedures rather than flawed employees more often cause these errors. By creating a safe learning environment in which all employees can share their misdemeanours, errors and near misses a culture of learning from losses can be created.

INCIDENT REPORTING IN HEALTH CARE – A PROACTIVE APPROACH

INTRODUCTION

Reporting and investigation of Incidents is by its very nature a reactive process. The challenge for Management is to turn this negative phenomenon into a positive opportunity for growth through the culture of learning by mistakes. In other words – Learning from Losses.

In the book “Lessons from Disasters – how organisations have no memory and accidents recur,” by T. A. Kletz, he discusses the repetitive accidents occurring in the Chemical Industry and he says that accidents recur because we do not use the knowledge we already have. Although Kletz has focussed on the Chemical Industry, the lesson is clear for all industries. In his article in the ICheme Loss Prevention Bulletin in 1995 he states that we are slow to learn from the experiences of others.

The historian E.H. Carr says “Modern man peers eagerly back into the twilight out of which he has come, in the hope that its faint beams will illuminate the obscurity into which he is going……” Kletz maintains that Carr is wrong. For those who are willing to look, it is searchlights, not faint beams that shine out of the past and show us the pits into which we will fall if we do not look where we are going.

Even when incidents are reported and trends identified, organisations can become victims of complex organisational processes. This was summarised in a presentation given by Corrie J Pitzer – Managing Director, SAFEmap, Australia as a “normalisation of deviance”. In this paper he demonstrates through examples of major disasters around the world such as Challenger, Piper Alpha and Mining disasters that even after extensive analysis of causes, the risk can be classified as ‘acceptable risk’.

In the Healthcare environment, patients, employees and doctors are exposed on a daily basis to life threatening situations. When continually subjected to risk, the risk becomes a relative issue and we increase our ability to accept risk. What was abnormal yesterday becomes safe and acceptable today. A level of complacency develops where the risk is accepted as the norm. Four hundred years ago, Pascal wrote “When everyone is moving towards depravity, no-one appears to be moving. But when someone stops, he shows up the other by acting as a fixed point.”

Let us in health care now stand still and review the norm of non-reporting and the benefits of a culture of learning from our losses.

CRIMINAL IMPLICATIONS OF INTERNAL INVESTIGATIONS

In a newsletter published by Klass Looch and Associates – Occupational Legislation Consultants, he states how employers may not be aware that internal investigations conducted as required by law including any statements made in the course of the investigations, have lost their confidentiality in recent years, and must be made available on the request of a legal practitioner during formal inquiries. This development has its roots in the Constitution and can impact quite dramatically on the employer’s honesty as he may incriminate individuals as well as the company if subsequent criminal or civil action were to arise.

Although this is a de-motivating factor for Management to conduct thorough investigations, we can turn the reporting and investigating of incidents into a more positive approach by concentrating our attention more on the incidents that have a potential i.e. Near Miss reporting where there is no legislative requirement and no injury. There is, however, a great deal of information to be gathered and acted upon. Practise makes perfect and the cause analysis of near misses is an opportunity to also gain expertise in this area without having any negative legal consequences.

INCIDENT REPORTING

Not only can we learn from actual consequential accidents, (an after the fact), but also we can turn the learning into a proactive learning tool approach by reporting and investigating all types of incidents.

What is an accident and what is an incident?

There are many definitions used. One definition used extensively for an incident is:

“An unplanned event that has caused (or could have caused) loss in the form of death, injury, illness, environmental or property damage, or business interruption.”

In this definition, an incident refers to both an event that has caused a loss of some kind and an event that could have caused (has the potential to cause) a loss. The first event being an accident and the second a near miss.

We never plan to have an accident and it is very seldom a single event that results in the loss. It usually occurs when a sequence of eventstake place that has a cumulative effect (cause and effect) and results in some form of loss.

A ‘Near Miss’ occurs when the same sequence of events takes place, but the only difference is that it does not result in the final consequence or loss. In other words, it has only the potential to result in a loss.

From this line of thinking, the definition for an incident could more accurately read:

“An unplanned sequence of events that have caused, or could have caused, loss in the form of death, injury, illness, environmental or property damage, or business interruption.

Near Miss reporting approach gives us the opportunity to learn from the same sequence of events that has no consequence. A more proactive approach could be adopted by finding the basic causes through cause analysis and putting in corrective measures before it becomes a loss. It is a free object lesson that we need to shamelessly exploit

NEAR MISS REPORTING IN THE HEALTHCARE ARENA

There are presently both in America and Europe concerted efforts to make inroads into the area of near miss reporting.

In a paper “Exploring ‘near misses’, the key to improving patient safety - a CEO task force debut” - 6/7/2000 by Rick Dana Barlow, Richard Norling[2] announced the formation of a healthcare industry-wide CEO –level task force of 11 top executives from the provider, payer and supplier sectors to identify and implement processes to reduce medical errors and improve patient safety. At his Washington-based headquarters of the Healthcare Leadership Council, Norling said that the task force will concentrate its efforts on areas other than mandatory reporting, which deals with the problem only after it occurs and generally results in blame. Instead they will focus on near misses and error-prone processes.

He quotes “I think it’s sad that this issue has crystallised around mandatory reporting, which has created an environment of fear and liability. You have to create an environment where people can come forward and freely talk about near misses so we can learn how to prevent errors from taking place.”

The Blue Cross Blue Shield of Michigan Foundation is working with this coalition. Ira Strumwasser[3] called researchers for a program to reduce accidental injuries in hospitals. (2/19/2001)

In the American Society of Health-System Pharmacists Statement on Reporting Medical Errors, their position for support is clear.

1)A uniform nation-wide system of mandatory reporting adverse medical events that cause death or serious harm,

2)Continued development and strengthening of systems for voluntary reporting of medical errors, and

3)Strengthen efforts to implement process changes that reduce the risk of future errors and improve patient care.

The primary concepts of voluntary reporting as detailed in statement are :

Quality improvement and enhancement of patient safety

Report analysis and communication lead to prevention of similar occurrences

Protection granted to individuals who submit reports to voluntary reporting programmes.

THE RELATIONSHIP BETWEEN ACCIDENTS AND NEAR MISSES

In the Bird Triangle where more than one million accidents of different types were evaluated, the relationship between the events that result in a consequence and those that resulted in no injury was 1/10/30/600

i.e. For every one major loss (death or disability) there were 10 medical treatment cases, 30-property damage and 600 near misses.

Four other studies done established the trend between potential consequences and actual consequences as follows:

Heinrich:1 Major or lost-time injury, 29 Minor injuries, 300 No injury

HSE: 1 Over three-day injury, 11 Minor injuries, 441 Non-injury

BSC: 1 Fatal/serious injury. 3 days lost-time injuries, 50 First aid injuries, 80 Property damage,

400 Near Misses

Whilst there are variations, each study demonstrates very clearly that for every serious, major or catastrophic incident, a large number of near misses will have occurred. The important message from these triangles is that there are many opportunities for correcting deviations, if only we knew about them. And when knowing about them, we must actively identify the underlying causes and determine effective solutions to prevent the injury from occurring.

REPORTING OF NEAR MISSES

Before we can start learning from losses or potential losses, we will need to know about them. This is easier said than done.

In a Japanese article published by Pub Med on “Factors affecting medication errors”, the paper revealed factors that may occur or that may prevent medication errors. An Investigation was conducted at a 650-bed university hospital and a 150-bed private hospital in Tokoyo in 1991. Nurses were given a questionnaire and requested to identify medication errors that they had personally committed within the past month. 70% responded. Results indicated that:

  • the nurses reported 10 times more errors than they had reported to the head nurses.
  • 56% of 155 nurses stated they had made medication errors during the 1-month period and
  • 30% said that they had dealt with medication errors occurred by others.

In a retrospective review of transfusion errors in a large teaching hospital conducted by Aberdeen and North-east Scotland Blood Transfusion Services[4], they found true incidence of errors to be at least 4 times the actual miss-transfusion events detected. 75% of the errors were detected as near misses.

In this article they support the theory that for nurses to be effective “they must practise in environments that recognise the importance of reducing error and improving safety through use of non-punitive system approaches to analysing near misses and errors. The ‘off-with-their-heads’ approach must be eliminated.”

BARRIERS TO REPORTING:

The barriers to reporting are many and some quite complex as we are dealing with individual’s fears, perceptions, likes and dislikes etc.

Some of the important ones are:

Fault finding rather than fact finding: This is the main reason why near misses are not reported. This leads to a culture of finger pointing, blaming and punitive measures. The quickest way to stifle reporting of incidents is to conduct disciplinary procedures without conducting detailed investigations.

A culture of blaming the employees: Frequently when conducting cause analysis we find statements like “nurse must be more careful” “attitude of nurse needs to change” and the like. On the other side of the coin, blaming management is just as harmful.

People do not want to be found ‘incompetent’. We all have a natural instinct to gloss over (if not cover up) our misdemeanours. We do not want to be found wanting or inferior, particularly when we are in charge of an area.

Time Wasting: It takes up valuable time to fill in a long report of an incident and then take part in the resultant investigation. If report forms are not easily available, the opportunity will be lost and the employee will not report it.

Lack of Trust: Employees are fearful and even when an organisation supports the culture of fact finding rather than fault finding, we find that many are still reluctant to come forward.

A PROCESS TO FOLLOW

A simple methodology that will encourage both management and employees to report all types of incidents is necessary to overcome some of these barriers to reporting and foster a culture of learning from losses. Using the acronym REPORT we can give some pointers to a healthy attitude towards reporting.

When an event occurs:

R-React positively

E-Evaluate basic (direct) and underlying (root) causes

P-Prevent a recurrence by developing effective controls

O-Opportunity to share the learning that takes place

R-Report Form – User-friendly, uncomplicated report form

T-Trends identification to prevent similar incidents

React Positively

Right at the outset of an event occurring, the attitude of the line manager and others in the vicinity can set the tone. To start the process as soon as possible and deal with it quickly has many advantages. . It is here that valuable information can be gained that could be crucial to the cause analysis. Also any event that has occurred should not be left hanging like a “sword of Damocles” over the head of the persons involved.

A team approach of suitably trained persons, preferably from the unit where the event occurred, will also lead to a more objective analysis.

Evaluate the Causes

The credibility of the reporting culture will be seriously impaired if the cause analysis is superficial. Conversely, if the analysis is faulty and blame is incorrectly apportioned, the employees will become distrustful of the process.

Various methods can be used such as Causal Tree, Fault Tree Analysis, Hazop/Hazan and the like. All the systems have one important thing in common. They are a systematic and logical process of sorting out the facts in an objective way to uncover the basic (direct) and underlying (root) causes. When gathering the facts, practise the culture of fact finding and not fault finding. Give training to all staff on non-threatening questioning techniques. The cause-effect process is continuous and after writing down and constructing the causal tree or fault tree, more questions will arise that will require further investigation. What happens after the fact gathering exercise will be determined by what causes have been identified.