What are Incidents?
The HSE (2018) defines an Incident as an event or circumstance which could have, or did lead to unintended and/or unnecessary harm. Incidents include adverse events which result in harm; near-misses which could have resulted in harm, but did not cause harm, either by chance or timely intervention; and staff or service user complaints which are associated with harm.
Incidents can be clinical or non-clinical and include incidents associated with harm to patients, service users, staff and visitors, ICT systems and data security, the environment and corporate reputation.
Some of the sources of an incident include internal system/process failings; medication adverse event / medication errors / potential adverse drug event; health and safety issue or incident; reportable events, e.g. outbreak of any notifiable disease; and security breaches.
Incident or potential incidents may be identified by any member of staff through direct observation or involvement and/or Quality and Safety Mechanisms (audits, external assessments).
In many cases, the causes of incidents are due to failures or weaknesses in the systems of care or management rather than the actions of an individual. The key to improving safety lies therefore in addressing any inherent weakness in the system rather than focusing solely on an individual’s actions or inactions (HSE, 2018).
All staff have responsibility to report incidents or potential incidents in a timely manner. It is important for staff to provide sufficient information when reporting. It is proposed to document all incidents or potential incidents in the first instance and to report, incidents or potential incidents, as soon as possible after identification to the appropriate Line Manager.
Analysis of Incident Data
The review and analysis of incidents should be viewed as a key tool to enhance quality improvement in a service. Data analysis will allow a service to:
- Find out what happened and why it happened
- Recognise factors that contributed or influenced the occurrence
- Identify common themes e.g. trends in falls patterns
- Identify required areas for review and improvement and allow for controls to be implemented to reduce likelihood of recurrence
- Make informed decision making
- Enable Senior Management to have an adequate oversight of the issues in which the organisation currently faces
- Identify learning that can be gained in order to minimise the risk of a similar incident occurring in the future.
Trend analysis of incident data should contain examination of information, including:
- A comparison of incident types and numbers over a period
- Identified trends by site/time/location/staff involved/individual involved, circumstances and any other pertinent information
- Identified reasons for the trends and increases/decreases in incidents
- Identified systemic changes implemented based on incidents reported and an analysis of where these changes were effective
- Recommendations for future actions.
Communicating Lessons Learned
Anecdotally and through the completion of Governance and Serious Incident Reviews it is evident that “lessons learned” have not been implemented and provided to front line staff within various healthcare organisations resulting in recurrence of consequential incidents. An example of this would be the Tania McCabe Inquiry in 2007 and the Savita Halappanavar Inquiry in 2012. The similarities between the two cases was “probably one of the most disturbing findings” (HIQA, 2013). Of the 19 public maternity units, only 5 implemented the 27 recommendations made in 2007. Of the remaining 14, six reported their status against a different investigation or gave no comment. A number of the six reported that evidence for implementation was not in existence. This was noted by HIQA as “unsatisfactory and concerning”.
Where recommendations and learnings arise from the management and review of specific incidents and adverse events, lessons learned should be developed by the organisation and used to inform the development of best practice and improve the service provision across the organisation in line with providing the highest standard of quality and care. Service providers also need to reflect on the findings of national and international investigations and implement the appropriate recommendations.
It is also imperative that each organisations’ Management team ensures an effective staff communication structure is developed, implemented and resourced within the organisation. Internal communication methods must foster communication in the delivery of clinical and non-clinical services and the actions required in promotion of a safe environment, through the review and communication of incidents and required actions. Lessons learned can be provided to staff members in a variety of formats including communication at handover, team meetings, a one to one discussion, group discussions or through dissemination of staff leaflets and ad-hoc information sessions.
In conclusion, monitoring and analysing of incident data is crucial to reduce the number of incidents from happening or reoccurring. Analysing incident data can help organisations identify factors that contribute to incidents, allowing them to put controls in place to reduce the likelihood of an incident happening or reoccurring. We have learned from past events that it is important to communicate lessons learned from incidents and near misses. This is an important tool to increase the recurrence of desirable outcomes and reduce the recurrence of undesirable outcomes.