Incident reporting and patient safety
BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39071.441609.80 (Published 11 January 2007) Cite this as: BMJ 2007;334:51
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Dear Editor
Re. Incident reporting and patient safety
Is the current NHS Hospital Patient Safety Incident Reporting scheme
a waste of time?
Is it worsening patient care by diverting time from the care of
patients to the completion of forms?
Why is the UK General Medical Council requiring us to report all
clinical incidents1?
Is there good quality evidence that the reporting of extremely large
numbers of minor incidents is improving patient care?
What is the evidence that a reporting system base in an NHS district
general hospital improves patient care?
Why do hospital trusts ask us to report all incidents, when they only
look in detail at the minority of most serious (“orange” and “red”)
incidents?
According to the study by Sari and colleagues2 there will be (on
average) one incident reported for every 3 hospital admissions. It takes
approximately 20 minutes to find the incident reporting book, complete it
and return it to the relevant person / place (educated guess). If all
incidents were reported (as is required by the UK General Medical
Council1), how much medical and nursing time would this consume? This time
would either mean that other patients would receive less care or staff
would leave late. Neither is a strong motivating factor for completion of
patient incident reporting forms. The Chief Medical Officer for England
(Professor Liam Donaldson) clearly sees this as a problem3.
The editorial states that “analysing a small number of incidents
thoroughly is probably more valuable than a cursory overview of a large
number of incidents”4. Yet we are being asked to report an enormous number
of incidents.
Is it possible that patients are being harmed by the system because
more time is being spent filling in forms (which provide little benefit)
rather than caring for patients?
1.http://www.gmc-
uk.org/guidance/current/library/management_for_doctors.pdf
2.Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine
system for reporting patient safety incidents in an NHS hospital:
retrospective patient case note review. BMJ 2007;334:79-81
3.http://www.dh.gov.uk/assetRoot/04/14/16/72/04141672.pdf
4.Vincent C. Incident reporting and patient safety. BMJ 2007;334:51
Yours faithfully
Dr Peter Gibson
Competing interests:
None declared
Competing interests: No competing interests
Systematic failure to deter daily clinical errors.
By “patient safety incident” does Professor Vincent actually mean the
opposite, ‘potential or actual patient harm incident’ — which term would
perhaps concentrate minds better [1]? He provides no clinical example to
illustrate his view and aim. How would his plans function to rapidly
identify
and stop recurrence of an “incident” of a doctor taking a slipshod
clinical
history resulting in a dire yet preventable outcome?
He was a “paid adviser” for the expensive NPSA which thought “the
reporting
of incidents” was a good idea. He now sees “the vast amounts of money
poured into this” as near useless (hence his article). He confides it was
“hard
to see why” they went down that cul-de-sac (ie. why they wasted tax-
payers’
money). Patients would agree. He wants instead “systematic data
collection”,
“systematic assessment of error and harm” and “if incident reports are to
be
of real value they should be reviewed by clinicians”. Yes. Independent
clinicians. Nationwide and daily [eg. 2,3]. Complaints are crucial
“incidents”
and are one excellent place to start – although Vincent bemoans that
“their
management dominates” things. So it should. And many complaints need a
more definitive action than “review”.
He wants “active surveillance of salient events” and then “analysis
and safety
improvement programmes” — which terms smack of the lofty intentions and
undefined action with which medico-politicians feel so comfortable, not to
mention their expense. Patients themselves know what is needed to curtail
clinical errors and Vincent (who is in “research”) might usefully ask them
–
starting with those who have been touched by medical error. There is
plenty
of choice.
William G Pickering.
wgpi@hotmail.com
17.1.07
References:
1. Vincent C. Incident reporting and patient safety BMJ 2007;334:51
(13
January)
2. Pickering W.G. An independent medical inspectorate. In: Gladstone
D, ed.
Regulating doctors. London: Institute for the Study of Civil Society,
2000:
47-63. ISBN 1-903 386-01. [http://www.civitas.org.uk/pdf/cs01.pdf]
3. Pickering W.G. Systematic clinical accountability is required.
BMJ Nov 2003; 327: 1109
Competing interests:
None declared
Competing interests: No competing interests
It is less important to get new numbers or data. We have enough
knowledge about safer working conditions and safer health care. It is much
more important to get "to the heart of the doctors" (Colin Feek, Ministry
of Health, NZ). You will get good information from reporting systems if
the ones who are responsible for the local system (e.g. hospital managers)
are working with this information. If you don't act on patient safety
information, if numbers and data are used to threaten or to shame doctors
and nurses, all activities will fail. And, mandatory systems are always
voluntary, because you decide what to tell.
Competing interests:
None declared
Competing interests: No competing interests
I welcome this editorial (1), and the linked paper(2). Sadly I
suspect most health systems operate on a basis of shooting the messenger
rather than welcoming reports of incidents. The NHS may be supposed to be
a learning organisation but I suspect it has the learning ability of a
patient with Altzheimer's. The rapid changes and waves of
redisorganisation help it to forget very easily.
Despite the rhetoric most parts of the NHS are still defensive and
trying to avoid and reduce complaints and incident reports. They want a
few to show they are doing something, but not too many, or any that they
have to do anything about.
For practitioners at present few of us believe that any useful action
will flow from reporting an incident.
1. Vincent, C (2007) Incident reporting and patient safety
BMJ 2007; 334: 51
2. Ali Baba-Akbari Sari, Trevor A Sheldon, Alison Cracknell, Alastair
Turnbull (2007)
Sensitivity of routine system for reporting patient safety incidents in an
NHS hospital: retrospective patient case note review
BMJ 2007;334:79
Competing interests:
None declared
Competing interests: No competing interests
Using Word[R], I create printed out, computer generated memoranda,
containing the now old fashioned form called the “sentence”, keeping a
copy for reference. This, rather than fill the endlessy fenestrated
computer based Incident Reports which, apart from what Vincent says[1],
can be used by nurses as vehicles for bullying and victimization.
For example, an anonymous concerned reporter names an individual but
makes no entry in the clinical record. We have a computer incident
reporting system here called ‘PRIME’, and insecure nurses who fail as
leaders tend to threaten other nurses with such gems as ……“I’ll PRIME
you”.
That said, here in Australia, the National In-patient Medication
Chart[NIMC] is in operation as of 2006[2]. The NIMC is a response to
patient safety concerns related to medication error, caused in part, by
having too many different versions of medication charts in one hospital
and also in different hospitals in the same country[2].
While this standardization seems common sense, it is not yet
accompanied by any standardization of the two ring A4 document folder
containing the NIMC, or “bed chart” which usually resides at the foot of
the bed, but which can be found anywhere in the ward in use by any number
of health care workers.
Leaving aside actions of basic life support[BLS] - it is precisely
because these document folders/bed charts are highly mobile, that their
speedy location becomes important in any medical emergency, as a quick
overview of the patient’s current medication administration record is
vital, and starts the process of addressing the question…….
“Do our current actions or omissions in medication
administration/prescribing help explain the emergency? ”…….
Identifying the “bed chart” by bed number is the usual means of
quickly locating it, in the absence of any electronic record via a mobile
device. This is followed by confirming ID using the labels on the scripts.
Yet labelling of bed chart/document folder itself, seems left to what may
be called “diversity principles”, and any number of unauthoritative and
arguably dangerous bed number labelling efforts can be seen.
The saddest and most minimal of these efforts which comes to mind
was a badly written bed number in biro on a piece of paper towel held in
place by several pieces of visibly soiled porous surgical dressing tape,
under which was a different bed number in felt tipped pen. When the sad
paper label fell off, the patient in one bed got the medicine meant for a
different patient.
One might have thought that the vast resources and buying power of
the health care system would have, by the third millennium, produced a
bed chart/document folder which is a disposable consumable, which protects
patient details from casual observation, which is labelled professionally,
authoritatively, clearly, unambiguously, which is washable, which can be
identified from several angles. And so on.
[1] Vincent C. Incident reporting and patient safety. BMJ
2007;334:51
[2]http://www.safetyandquality.org/internet/safety/publishing.nsf/Content/n...
-inpatient-medication-chart
Competing interests:
None declared
Competing interests: No competing interests
Errors in judgmet : To report or not to report?
Much can be said about patient’s safety. In most everyday scenarios,
we are talking about mistakes by junior doctors in training or by non-
medical/para medical staff. What happens when the error of judgment comes
from much senior person, i.e. Consultant. In the current system in NHS,
Consultant is where the buck ends. They take overall responsibility for
patients care. Often they have to answer, even when patient is admitted
under their care. What happens really when the mistakes comes from the
Consultant? To make it worse, if this gets spotted by someone junior? Is
it ethical for the junior to turn a blind eye? Should the junior become
more vigilant? Should the junior report to whosoever it matters and risk
being labelled a whistle blower and incur the wrath of the management?
There are many guidelines, but when it comes to facing the
guillotine, why the juniors get sidelined? Manipulation of people and
forces become apparent and suddenly, the juniors training is questioned?
Junior find him/herself alone, unsupported, being placed under extreme
supervision and alone to defend oneself.
Is this system failure? I feel that this is very cynical. This
emerges form the belief we have grown up with that “Consultant knows
everything”. Alas! That’s not the case in many situations. Especially,
with training time getting shorter and doctors spending more time in acute
on calls and less for speciality training. The pressure from the EWTD is
a confounding factor in reducing quality training and the training has
actually shrunk to getting some pieces of papers signed, ticks in
appropriate boxes. Gone are the days when clinical experience did matter.
Gone are the days when clinical skills were hammered into. Now a day, as
long as one gets signed off for a task, and has shown competencies in a
paper, they are competent. Is it true? Rising number of incident reporting
mirrors this.
SO god me when I am old and I have to spend my time on a trolley which
gets moved from A/E to MAU to Clinical decision unit to ward, in worst
case scenario, moved to a different hospital, as I am breaching trolley
wait time in one area/hospital. I will also have to prey that some one who
has all the ticks would treat me and all competencies signed for.
So help me god. I am a pessimist? No, Just hopeful.
Competing interests:
None declared
Competing interests: No competing interests