Incident Report Form Research Articles

Perioperative and Anesthetic Adverse events in Thailand (PAAd Thai) incident reporting study: anesthetic profiles and outcomes

Background: The Royal College of Anesthesiologists of Thailand initiated registry and reporting of anesthesia service incidents and outcomes in 2005. Objectives: The Perianesthetic Anesthetic Adverse Events in Thailand (PAAd Thai) study aimed to investigate patient, surgical, and anesthetic profiles, and suggest strategies for prevention of adverse events. Methods: A prospective descriptive study was conducted in 22 hospitals across Thailand. Each hospital was invited to report, on an anonymous basis, any perianesthetic adverse incident during 12 months (between January 1 and December 31, 2015). A standardized incident report form was completed to determine the type of incident, and where, when, how, and why it occurred using closed and open-ended questionnaires. Data regarding main anesthetic techniques were also reported monthly. Descriptive statistics were used. Results: For 333,219 cases, 2,206 incident reports with 3,028 critical incidents were reported. The incidents commonly occurred in male patients (52.0%), aged 70 y (18.2%). The incidence of adverse events included cardiac arrest within 24 h (15.5:10,000), death (13.0:10,000), reintubation (11.1:10,000), esophageal intubation (8.5:10,000), difficult intubation (8.0:10,000), and malignant hyperthermia (1:200,000). General, cardiothoracic, neurological, and otorhinolaryngological surgical specialties posed a high risk of incidents. Operating and recovery rooms were common locations for incidents. Conclusion: In the past decade, there were dramatic reductions of perioperative cardiac arrests and difficult intubations. Common factors related to critical incidents were inexperience, emergency, inadequate preanesthetic evaluation, inappropriate decisions, lack of vigilance, and inexperienced assistants. Suggested corrective strategies are compliance with guidelines, additional training, and improvement of supervision and quality assurance. Keywords: Adverse events, anesthesia, incidents, incident report, patient safety

Warning Signs prior to Aggressive Behavior in Child Psychiatric Units

This study aims at detecting and categorizing early warning signs of aggressive behavior in child psychiatric units. We analyzed 575 violent incident report forms and developed a coding scheme consisting of 16 warning signs. From the 575 incident report forms, a total of 1087 signs were coded. Most common warning signs were ‘restlessness’ (21.2%), ‘not listening’ (15.2%) and ‘anger’ (9.8%). These were also the most prevalent warning signs for the severe incidents. Although warning signs differ for each individual child, this study indicates that there are common warning signs for imminent aggressive incidents in child psychiatric facilities.

Care planning for aggression management in a specialist secure mental health service: An audit of user involvement.

This paper describes an audit of prevention and management of violence and aggression care plans and incident reporting forms which aimed to: (i) report the compliance rate of completion of care plans; (ii) identify the extent to which patients contribute to and agree with their care plan; (iii) describe de-escalation methods documented in care plans; and (iv) ascertain the extent to which the de-escalation methods described in the care plan are recorded as having been attempted in the event of an incident. Care plans and incident report forms were examined for all patients in men's and women's mental health care pathways who were involved in aggressive incidents between May and October 2012. In total, 539 incidents were examined, involving 147 patients and 121 care plans. There was no care plan in place at the time of 151 incidents giving a compliance rate of 72%. It was documented that 40% of patients had contributed to their care plans. Thematic analysis of de-escalation methods documented in the care plans revealed five de-escalation themes: staff interventions, interactions, space/quiet, activities and patient strategies/skills. A sixth category, coercive strategies, was also documented. Evidence of adherence to de-escalation elements of the care plan was documented in 58% of incidents. The reasons for the low compliance rate and very low documentation of patient involvement need further investigation. The inclusion of coercive strategies within de-escalation documentation suggests that some staff fundamentally misunderstand de-escalation.

The German Critical Incident Reporting System for Anesthesiology

In June 2010, the Helsinki Declaration was passed. As a result, an online nationwide critical incident reporting system named CIRSmedical Anaesthesiology (CIRSains) was implemented in Germany. The aim of the article is to evaluate CIRSains for practicability and to provide solutions to the problems detected during evaluation. Every medical staff member could take part voluntarily. Data were deidentified. All reports for anesthesiology (1548) were taken into account. Data collection lasted from April 2010 to February 2011. Incident report forms were classified according to World Health Organization and National Patient Safety Agency taxonomy. Most reports (1347; 87.0%) contained American Society of Anaesthesiologists (ASA) classification, stratifying the severity of patients' underlying disease. Only some mentioned patients' age, even less sex. Physicians filed more reports than nurses. Staff-related factors constituted 794 (51.3%) choices, with attention issues (433; 28.0%) and routine violations (143; 9.2%) leading. Clinical processes (443; 28.6%), medication (347; 22.4%), and medical devices (530; 34.2%) were the leading incident category types. Most consequences ranged in low (398; 25.7%) and moderate (826; 53.4%) risk categories. Mitigating factors were barely mentioned. CIRSains displays the German effort to establish the Helsinki declaration. Easy accessibility, anonymity, medicolegal safety, and high flexibility resulted in high usage. The study shows a sufficient practicability of the database, but the data input has to be improved for better scientific use, for example, by implementation of more multiple-choice questions. Given the high magnitude and importance of patient safety problems, improving CIRSains remains a priority for the future.

Patients’ willingness to complete written incident report forms in one UK tertiary cancer hospital

This article examines patients’ willingness to complete incident report forms, providing a description of the event or concern. Differing from other studies, its design enabled patients to report incidents when and if they felt this necessary, rather than responding to researchers’ questions. A total of 145 patients receiving treatment for cancer in a UK hospital were invited to participate. Of the 100 patients who agreed to participate, only 13 completed a total of 22 forms. The form’s purpose was not easily understood, often perceived as complaining and patients tended to report relatively trivial matters. Contrary to previous studies, this study found little evidence that incident report forms are the right tool for enabling patients’ proactive involvement in safety improvement. Asking patients to monitor their safety by completing incident report forms may serve to undermine patients’ trust in their clinicians while duplicating resources.

SU‐E‐P‐07: Retrospective Analysis of Incident Reports at a Radiology Department: Feedback From Incident Reporting System

Purpose:To provide an overview of reported incidents that occurred in a radiology department and to describe the most common causal source of incidents.Methods:Incident reports from the radiology department at the University of the Ryukyus Hospital between 2008 and 2013 were collected and analyzed retrospectively. The incident report form contains the following items, causal factors of the incident and desirable corrective actions to prevent recurrence of similar incidents. These items allow the institution to investigate/analyze root causes of the incidents and suggest measures to be taken to prevent further, similar incidents. The ‘causal factors of the incident’ item comprises multiple selections from among 24 selections and includes some synonymous selections. In this study, this item was re‐categorized into four causal source types: (i) carelessness, (ii) lack of skill or knowledge, (iii) deficiencies in communication, and (iv) external factors.Results:There were a total of 7490 incident reports over the study period and 276 (3.7%) were identified as originating from the radiology department. The most frequent causal source type was carelessness (62%). The other three types showed similar frequencies (10–14%). The staff members involved in incidents indicate three predominant desirable corrective actions to prevent or decrease the recurrence of similar incidents. These are ‘improvement in communication’ (24%), ‘staff training/education’ (19%), and ‘daily medical procedures’ (22%), and the most frequent was ‘improvement in communication’. Even though the most frequent causal factor was related to carelessness, the most desirable corrective action indicated by the staff members was related to communication.Conclusion:Our finding suggests that the most immediate causes are strongly related to carelessness. However, the most likely underlying causes of incidents would be related to deficiencies in effective communication. At our department, therefore, the primary action to prevent/reduce similar incidents should be ‘communication improvement’.

Incident Reporting Culture in Recreational Hot Air Ballooning

Hot air ballooning incidents are relatively rare; however, they have a high potential to be fatal. In order to inform appropriate safety interventions it is first necessary to understand the causal factors which lead to incidents and near-misses, which requires a formal incident report database. The Australian Balloon Federation (ABF) advocates the reporting of recreational hot air ballooning incidents, by reporting directly to the ABF safety officer or by completing an online incident report form. The objective of this paper is to understand how widely used the reporting system is and whether there are any perceived barriers to reporting. Sixty-nine balloonists participated in an online survey about their experience of incident reporting. Survey respondents were mostly male (11 female), experienced balloonists (mean years’ experience ballooning 19.51y with a SD 11.19). Sixty respondents (87%) held a pilot license. The majority (82.6%) of respondents were aware of the ABF incident reporting system. Over half (62.3%) had been involved in a ballooning incident or near-miss in Australia. However, 40% of those who had an incident or near-miss did not report it to the ABF and only 15.9% of all those surveyed had used the online incident report form. There was some disagreement regarding when it was appropriate to report an incident or near miss. Some respondents felt an incident or near miss should only be reported if it resulted in injury or damage, while others said near-misses should also be reported. The most frequent barriers identified were: a lack of understanding of when to report to the ABF; trivializing of incidents; and concerns about the system itself Steps should be taken to increase understanding of the system purpose and long term benefits. Specifically, reporting near-misses should be encouraged. This study is significant because it is the first to examine reporting practices in non-motorised recreational aviation.

PS-075 Evaluation of fall risks in elderly patients

BackgroundFalls among hospitalised elderly patients are a major public health concern since they can cause loss of independence, injury and sometimes patient death.PurposeTo examine risk factors, especially drugs, potentially related...

Leisure-related injuries at the beach: An analysis of lifeguard incident report forms in New Zealand, 2007–12

From 2007–2012, New Zealand lifeguards provided first aid to almost 9,000 beachgoers, an average of 1,772 cases per annum; more than the average number of rescues (n = 1,343) each year. This study describes the aetiology of non-drowning related injuries occurring at surf beaches patrolled by lifeguards. The study design was that of a retrospective analysis of data collated during five summer seasons from 2007–2012. Cases included individuals who sustained recreational injuries while at a patrolled beach in New Zealand. Incident report forms, routinely completed by lifeguards in New Zealand, were the data source for this study. Of the 8,437 incidents evaluated, 57% of the patients were males, one half (52%) were aged less than 16 years. Most injuries (82%) were minor, almost half (43%) were to the lower limbs. Half (54%) of the injuries were sustained in the water, one third (32%) were attributed to land-based activities. Cuts/abrasions accounted for almost half (47%) of all injuries. First aid responses for both water and land-based incidents are indicative of the nature and extent of recreational injuries sustained at the beach. The diversity and frequency of such incidents suggests that public education promoting beach safety is warranted.

Survey on critical incident reporting in a child and adolescent mental health service

To examine the prevalence and nature of critical incident reports at a generic child and adolescent mental health service. This is a retrospective survey of all critical incident reports completed at a community based child and adolescent mental health service between 2008 and 2011. Information was obtained about the nature of incidents and actions taken. In a three year period, only eighteen incident report forms were completed. Staff were most frequently the victims of the incidents (50%, n = 9), followed by clients (38.8%, n = 7) and parents of clients (11.1%, n = 2). Falls were the most common incident reports (44.4%, n = 8). Two incidences were related to physical aggression and threatening behaviour by clients. Critical incident reporting was found to be uncommon overall. Most of the recorded incidents involved staff members and were of minor significance. Specific training for staff regarding incident reporting should be provided to ensure an acceptable standard of investigation is consistently carried out for all significant incidents.

‘I'm going to learn how to run quick’: exploring violence directed towards staff in the Emergency Department

BackgroundThe National Health Service (NHS) depends on a highly skilled workforce. Anything threatening the well-being of that workforce threatens the delivery of healthcare. Violence and aggression directed towards healthcare professionals...

Fall prediction according to nurses’ clinical judgment: Differences between medical, surgical, and geriatric wards

Objectives: To assess the value of nurses' clinical judgment (NCJ) in predicting hospital inpatient falls. Design: Prospective multicenter study. Setting: Six Belgian hospitals. Participants: Two thousand four hundred seventy participants (mean age 67.6 ± 18.3; female, 55.7%) on four surgical (n = 812, 32.9%), eight geriatric (n = 666, 27.0%), and four general medical wards (n = 992, 40.1%) were included upon admission. All participants were hospitalized for at least 48 hours. Measurements: Within 24 hours after admission, nurses gave their judgment on the question �Do you think your patient is at high risk for falling?� Nurses were not trained in assessing fall risk. Falls were documented on a standardized incident report form. Results: During hospitalization, 143 (5.8%) participants experienced one or more falls, accounting for 202 falls and corresponding to an overall rate of 7.9 falls per 1,000 patient days. NCJ of participant's risk of falling had high sensitivity (78�92%) with high negative predictive value (94�100%) but low positive predictive value (4�17%). Although false-negative rates were low (8�22%) for all departments and age groups, false-positive rates were high (55�74%), except on surgical and general medical wards and in participants younger than 75. Conclusion: This analysis, based on multicenter data and a large sample size, suggests that NCJ can be recommended on surgical and general medical wards and in individuals younger than 75, but on geriatric wards and in participants aged 75 and older, NCJ overestimates risk of falling and is thus not recommended because expensive comprehensive fall-prevention measures would be implemented in a large number of individuals who do not need it.

A New Incident Report Form Leads to Improved Foundation for the Lessons Learned Cycle

Collection after incidents is regularly done through pre-printed incident report forms. The reports tend to be incomplete. They frequently lack fundamental information since they do not fulfill criteria’s of a scope and details. One consequence is that reports with inadequate information and do not fulfill requirements of analysts are transferred into the analysis process. To improve, the author designed a new structured incident reporting form, based upon witness psychology, interview, and questionnaire research with focus on analysts’ requests. This is the third experiment where they compared their new structured form to the form at present used in the Swedish Armed Forces (NATO standard). The two previous experiments showed significant enhanced results regarding quality of collected information, and that the new form could capture knowledge, regardless of the character or context of the incidents. The present experiment evaluates the form in a military context, and the significant result from an earlier experiment was replicated.

The use of failure modes and effects analysis (FMEA) to review a medication incident reporting system in a hospital

BackgroundMedication incident reporting systems play a vital role in improving medication safety through the identification of medication incidents/near misses and learning from them. FMEA is an excellent tool to review...

Improving workplace incident investigations by enhancing memory recall

Purpose – Industrial incident investigations determine what caused an adverse workplace event so that preventative measures can be instituted and reduce the risk of such incidents happening again. Investigators gather evidence from multiple sources in an investigation and one such source is the people in, or around, the industrial incident. The purpose of the current study is to examine if recall strategy could affect eyewitnesses' recollections of a workplace incident.Design/methodology/approach – The current study is a 3 (Post‐Event Context: Think, Filler, Discuss)×2 (Incident Investigation Form: Psychologically‐Based vs. Standard Investigation Form) between‐subjects factorial design. Participant‐witnesses watched a simulated videotaped workplace incident (n=196) then either: thought about the event, discussed it with fellow witnesses, or engaged in an unrelated task. Subsequently, participants recalled the details of the adverse event on an incident report form: a Standard Investigation Form or a form ...

The frequency and importance of reported errors related to parenteral nutrition in a regional paediatric centre

Summary Aim To determine the frequency and significance of reported errors related to parenteral nutrition (PN) in a regional paediatric centre. Methods In our children’s centre, it is policy that “any unexpected event with an actual or potential detrimental effect on a patient is formally reported on an incident report (IR1) form” by staff. We therefore reviewed all IR1 forms related to PN between January’06 and June’09. The errors were categorised according to where in the PN process they occurred. Harm scores (severity of the error in relation to patient safety) were based on the framework of the American ‘National Coordinating Council for Medication Error Reporting and Prevention’ (NCC MERP). Results Over 18,588 PN days, 46 errors were identified, giving an error frequency of 0.24%. Of these, 5 (11%) occurred during the prescription process, 9 (20%) during the transcription process, 11 (24%) during dispensing, 7 (15%) during delivery of PN to the ward and 14 (30%) during the administration process. No errors were reported during the preparation/compounding process. 43 (94%) errors did not result in patient harm, while 3 (6%) errors resulted in temporary harm. Conclusions Reported PN related errors resulting in harm appear to be rare. Most occur during dispensing and administration suggesting that more robust checking procedures are required during these phases. The widespread reporting of non harmful errors indicates that staff have an appropriately low threshold for completing IR1 forms; these represent a valuable audit tool for improving patient safety.

The frequency and significance of errors related to parenteral nutrition (PN) in children

ObjectiveTo determine the nature, frequency and significance of errors related to the PN process in a tertiary paediatric unit.MethodsIn our children's centre, it is policy that ‘any unexpected event with...

General surgical adverse events in a UK district general hospital–lessons to learn

Background An adverse event (AE) is defined as an unintended injury or complication caused by healthcare management rather than the disease process that may prolong admission and lead to disability or death. This study retrospectively assessed all reported general surgery-related AEs in a district general hospital in the south-east of England. Methods All general surgical AEs arising from adult inpatient admissions between 2002 and 2007, that had been reported to the risk management team, following completion of the standard ‘Adverse Incident Report Form’, were retrospectively reviewed. Results There were 24,185 general surgical admissions over the period of the study; 461 AEs were reported (1.9% mean annual incident rate; 95% CI, 1.3%–2.5%). The majority (85%) were near miss or no injury events (category I and II) while serious/serious near-miss incidents accounted for just 2% of events. Communicative or administrative problems were implicated in 54% of cases while 12% arose from theatre/surgery-related failure. Of 58 medico-legal claims (0.24% of admissions) that were made, 16 (27.5%) progressed to the law courts for formal settlement. Conclusion The reported annual AE incident rate of approximately 2% is well below the national average: this may be due to pre-selection of general surgery-related AEs or represent under-reporting of incidents. The vast majority of AEs were related to administrative and communicative error. These areas must be addressed if patient safety and outcome is to be significantly improved.

Group‐based evaluations for pupil‐on‐teacher violence: The impact of teacher intervention strategy

AbstractAlthough extreme violence to teachers is rare, the fact remains that in the UK, 29% of teachers report having been physically assaulted by a pupil (ATL, 2008a). The ways in which responsibility for such assaults are attributed can have legal, educational and managerial implications. In the current study, teachers (N = 66), pupils (N = 68) and parents (N = 64) from a large secondary school in the UK read an incident report form outlining an incident depicting a pupil physically assaulting a teacher. The incident report was manipulated such that, prior to being assaulted, the teacher had either separated the assailant pupil from another pupil using a physical or non‐physical intervention. Results revealed that participating parents' and teachers' evaluations of the assailant's parents and the teacher differed from those of pupils in several ways. The results are discussed in terms of group‐based responsibility for deviant behaviour and implications for teacher behaviour in response to pupil on teacher violence. Copyright © 2010 John Wiley & Sons, Ltd.

The documentation and reporting of shoulder dystocia in a district hospital

BackgroundIn previous studies it has been suggested that proformas may improve the noting of shoulder dystocia (SD) management and outcomes.ObjectivesTo determine the method and accuracy of recording of the number...