Incident reporting in one UK accident and emergency department

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Summary

Greater focus is needed on improving patient safety in modern healthcare systems and the first step to achieving this is to reliably identify the safety issues arising in healthcare. Research has shown the accident and emergency (A&E) department to be a particularly problematic environment where safety is a concern due to various factors, such as the range, nature and urgency of presenting conditions and the high turnover of patients. As in all healthcare environments clinical incident reporting in A&E is an important tool for detecting safety issues which can result in identifying solutions, learning from error and enhancing patient safety. This tool must be responsive and flexible to the local circumstances and work for the department to support the clinical governance agenda.

In this paper, we describe the local processes for reporting and reviewing clinical incidents in one A&E department in a London teaching hospital and report recent changes to the system within the department. We used the historical data recorded on the Trust incident database as a representation of the information that would be available to the department in order to identify the high risk areas. In this paper, we evaluate the internal processes, the information available on the database and make recommendations to assist the emergency department in their internal processes. These will strengthen the internal review and staff feedback system so that the department can learn from incidents in a consistent manner. The process was reviewed by detailed examination of the centrally held electronic record (Datix database) of all incidents reported in a one year period. The nature of the incident and the level and accuracy of information provided in the incident reports was evaluated. There were positive aspects to the established system including evidence of positive changes made as a result of the reporting process, new initiatives to feedback to staff, and evolution of the programme for reporting and discussing the incidents internally. There appeared to be a mismatch between the recorded events and the category allocated to the incident in the historical record. In addition the database did not contain complete information for every incident, contributory factors were rarely recorded and relatively large numbers of incidents were recorded as “other” in the type of incident. There was also observed difficulty in updating the system as there is at least a months time lag between reporting or an incident and discussion/resolution of issues at the local departmental clinical risk management committee meetings.

We used Leape’s model for assessing the reporting system as a whole and found the system in the department to be relatively safe, fairly easy to use and moderately effective. Recommendations as a result of this study include the introduction of an electronic reporting system, limiting the number of staff who categorise the incidents – using clear definitions for classifications including a structured framework for contributory factors, and a process that allows incidents to be updated on the database locally after the discussion.

This research may have implications for the incident reporting process in other specialities as well as in other hospitals.

Introduction

In a high pressure system with complex decisions and multiple sequential actions, errors and adverse events will occur – the “clinical incident”. These may result in actual or potential harm to patients and are sometimes interpreted as ‘intentional’ or ‘careless’ actions. We remain accountable for the care we give but need to understand the complex factors that contribute to clinical incidents and these should be considered when an incident or a mistake has occurred. Any healthcare intervention carries a risk of harm, and reactions to drugs and infusions can be serious and even fatal. These incidents often have complex causes. The safety of patients is of increasing concern in many countries. The accident and emergency (A&E) environment provides a particular challenge because of staffing, high patient throughput, heavy dependence on services outside A&E (laboratory, radiology, consulting services, etc.) and the diversity of clinical conditions (Driscoll et al., 2001) as well as more recently the added pressure of the 4 h target (Department of Health, 2000a).

In this paper, we provide a brief overview of the patient safety movement and describe how a review of a local incident reporting system can be used to identify potential improvements in the safety of patients.

Several important new initiatives in the last few years underline the increasing attention paid to patient safety. High profile cases in several countries, such as the Bristol Inquiry into paediatric cardiac surgery in the UK and the similar Winnipeg inquiry in Canada played a part in raising public awareness and driving policy change (Smith, 1998). In the United States the report of the Institute of Medicine ‘To err is human; Building a Safer Healthcare System’ (Kohn et al., 1999) starkly sets out the scale of harm of patients. In the UK the Health Service Ombudsman has highlighted that the same errors occur again and again, and suggested that the NHS is not learning from errors quickly enough or taking appropriate action to prevent their re-occurrence (Health Service Ombudsman, HSO, 2003). The Department of Health commissioned a major report on ‘An Organisation with a Memory’ (Department of Health, 2000b), a report covering similar ground to the Institute of Medicine report. This has led to the establishment of the National Patient Safety Agency (NPSA), whose objectives are to collect and analyse information on adverse events; to learn lessons from these events and ensure feedback to practice; and to identify risks and produce solutions to prevent harm (http://www.npsa.nhs.uk/).

The development of clinical risk management in the United Kingdom and elsewhere led to the establishment of local incident reporting systems in hospitals, usually run centrally. Typically, there is a standard incident form, requiring basic clinical details and a brief narrative describing the incident. Sometimes staff are asked to report any incident which concerns them or might endanger a patient. In more sophisticated systems where staff within a unit may be trying to routinely monitor and address specific problems there may be a designated list of incidents, a trigger list, although staff are free to report other issues that do not fall into these categories. Generally, the incident is classified as to the type of incident i.e. drug error, lack of records, missed diagnosis, as well as allocating contributory factors. The incident is also scored in terms of likelihood of recurrence and the degree of severity of impact on the patient.

Local systems are ideally used as part of an overall quality improvement strategy but in practice are often dominated by the requirement to manage claims and complaints. The NHS has a well developed clinical incidents reporting system and this system should be seen as a tool by which patient safety issues can be identified and addressed to reduce the occurrence of clinical incidents and to improve both patient and staff experience. However there are still a number of barriers to reporting such as fear of reprisals, loss of reputation, extra work or poor understanding of the process of investigation of an incident (Barach and Small, 2000). Furthermore, there are mixed responses to the investigations of errors, some of which have the potential for learning and improving care (Meurier et al., 1997).

Section snippets

Incident reporting in the study Trust

In this paper, we outline the clinical incident reporting system in place in the A&E department of a London teaching hospital from March 2003 to March 2004. The Trust uses a Trust wide database of clinical incidents, the purpose of which is to identify trends in the type of incidents, record contributory factors and allow departments to learn from the incidents reported.

The purpose of the study was to evaluate the use and effectiveness of the reporting system as used in the A&E department. The

Method

The researchers reviewed 13 consecutive months of data from the A&E section of the Trust electronic database of clinical incidents. The data reviewed included the 174 incidents reported during the period from March 2003 to March 2004. The researchers used the free text information stored as the incident description on the database, and compared this with the category and the severity score recorded on the database. The contributory factors recorded and relevance to the clinical incident

Discussion

Incident information on the database was comprehensive enough to allow descriptions of the type and severity of incidents to be summarised. We know that not all incidents which occur are reported (Stanhope et al., 1999). There are various reasons for this (Barach and Small, 2000) which might explain why there are more near misses and minor events in this dataset than those judged to be serious or moderate.

Studies have also shown that even with explicit criteria and definitions, inter-rater

Acknowledgements

We thank the Department of Health Patient Safety Research Programme for funding this study. We are grateful to the staff and risk management committee members of the study Trust for allowing us to examine the data and for their comments.

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