Adverse incident reporting
The MDU's clinical risk managers regularly undertake workshops for PCTs, aimed at all members of the primary healthcare team. These are designed at helping practices control or eliminate risks to patients and staff in the surgery. This is a taster of one of the most requested workshops - Adverse Incident Reporting.
Publication date: 12 July 2002
"Experience is the name that every one gives to their mistakes," said serial quipper Oscar Wilde in Lady Windermere's Fan. Yet the NHS has been poor at learning from adverse experiences. A good example of this in the general practice setting is the recurring and potentially fatal confusion over the dosage of oral methotrexate used in the treatment of arthritis.
What is an adverse incident?
An adverse incident can be defined as "an event or circumstance that could have or did lead to unintended or unexpected harm, loss or damage".1
GPs already record or report complaints and accidents to staff, patients or contractors. Suspect drug reactions are logged using the British National Formulary yellow card system. And equipment malfunctions and breakdowns are reported to the Medical Devices Agency.
But an AIR system would mean that other potentially dangerous incidents such as breakdown of practice systems for dealing with test results, clinical errors such as failure to diagnose or medication errors would be logged on a simple pro-forma reporting form.
Why bother with AIR?
Around 400 people a year die or are injured due to adverse events involving medical devices and around 10,000 a year report a serious adverse drug reaction. However, the scale of the problem in primary care in the UK is unknown. But a study of general practice incident monitoring in the Medical Journal of Australia, published in 1998, revealed that four per cent resulted in death but that 76 per cent of events were considered preventable.2
Good fortune was stated as the most frequent mitigating factor and poor communication the most frequent contributing factor. By examining the underlying causes of incidents, which are often the results of systems failures, lessons can be learnt to prevent or minimise the risk of recurrence.
Any AIR system should collect not only information on adverse incidents themselves but also other events termed "near misses". For every major adverse incident there are likely to be a far greater number of minor events or incidents where no injury or harm occurred. These can be looked upon as free lessons.
AIR in practice
One person in each practice, such as the practice manager or a GP, should be designated to take responsibility for AIR. Duties would include:
- Ensure AIR forms are checked for details and accuracy
- Classify and assess if urgent action is required
- Investigate and take appropriate action
- Change practice policies and procedures if required
- Record adverse incidents to create a database
- Analyse patterns and trends
- Provide feedback to all staff
Any investigation should look further than the immediate human errors to the root causes of the incident, determining why the event happened and trying to identify and eliminate risks that could lead to a recurrence. An action plan can be created with an implementation timetable and a review date.
Some adverse incidents, particularly those that are more complex, may require a significant event audit (SEA) meeting where the case can be discussed in detail. During SEA meetings it is essential to allow all staff to have a say and feel that they are taking an active part in the process.
The overall aim of the process is to learn from mistakes and incorporate the lessons into improved practice.
AIR will soon be mandatory
Learning from adverse incidents is now becoming enshrined in NHS culture and will provide part of the evidence to meet the General Medical Council's requirements for revalidation, a five yearly assessment of a doctor's fitness to practice.
Last year the independent National Patient Safety Agency (NPSA) was set up by the Department of Health to implement and operate a mandatory national reporting system, learn lessons from errors and offer solutions and examples of good practice. It also set the target of reducing by 40 per cent the number of serious errors in the use of prescribed drugs by 2005. In August it issued guidance on identifying and recording significant incidents.3
The MDU suggests that practices establish their own internal AIR system now, which can be adapted when AIR becomes mandatory. Staff training is important in this process to encourage and explain to staff the importance of reporting incidents and how the process works. It is likely they will need reassurance that they will not be inappropriately blamed for an incident they report.
To that end, this year alone, the MDU has run more than 20 workshops on AIR and it is becoming one of our most popular risk management services.
We are soon to publish a booklet giving guidance to members on establishing an adverse incident reporting system within their practice. As well as providing practical guidance on setting up an AIR system the booklet contains example reports and analyses and a copy of a simple pro-forma reporting form.
AIR in action
Here's an example of how AIR might work in practice:
A patient attended a practice's minor surgery clinic for the removal of a lesion on her right index finger. Lignocaine with adrenaline was given as the local anaesthetic, error instead of plain lignocaine. This was recognised when the nurse began entering the details into the computer in the minor surgery log.
The patient rested in surgery. There were no apparent immediate complications. An explanation and apology were given to the patient and a follow up appointment arranged.
Although the patient suffered no apparent harm from the incident, the practice might decide that, as there was potential for major harm, such as arterial spasm and ischaemic tissue necrosis, the incident should be given a high risk rating. In examining the near miss, the practice may look into issues such as reviewing the minor surgery protocol, drug storage (eg separating lignocaine and adrenaline from lignocaine alone) and the appointment spacing in the clinic if there was pressure of time. Training issues may also be highlighted and the practice could decide to monitor minor surgery clinics for timings and allocation of appointments.
The practice will need to prioritise components of the action plan, set review dates and crucially provide feedback to all staff regarding any changes that take place and lessons that were learnt from the incident.
These lessons may be issues such as:
- Always check drugs before administration
- Allow enough time for procedures
- Explain and apologise to patients, if appropriate, when things go wrong
References
- Department of Health and NPSA, Doing Less Harm, August 2001. www.npsa.org.uk
- Bhasale AL et al. Analysing potential harm in Australian general practice: an incident-monitoring study. MJA 1998; 169: 73-76
- www.npsa.org.uk
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