Make healthcare safer with system-wide incident reporting

If the improvement of patient safety is at issue, healthcare providers tend to look only within their own department or institution. Attention is paid to safety along the integrated care chain, but this does not (yet) reach outside the perimeter of their own institution. It is predominantly older patients who are subject to multi-disciplinary integrated care involving more than one organization. This is known as system-wide integrated care.

This blog describes how system-wide incident reporting works and how it contributes to patient safety.

Status of system-wide incident reporting in healthcare

Research within the acute integrated care chain (general practitioners, ambulance care, first aid and the mental healthcare crisis team) indicates that the responsibility for patient safety in system-wide integrated care is insufficiently embedded (Hesselink et al, 2016). Managers and care professionals have their own legitimate reasons for this undesirable situation, but they are not happy with it. The causes of this situation include:

• The autonomous positions of the healthcare providers.
• Internal organizational interests.
• The patient safety policies of the parties within the integrated care chain.

In the acute integrated care chain, partners work in their own organizations on the preconditions for patient safety. Each integrated care provider reports incidents and conducts prospective risk inventories. However, this does not hold true for the system-wide integrated care chain; risks are not researched or examined in a systematic manner.

It is therefore important to gain insight into the risks within the system-wide integrated care chain in order to take patient safety to the next level.

>> Learn more about the integrated care chain in our blog post "The impact of Continuum of Care on patient safety".

Causes of incidents

Many incidents with patients and healthcare professionals can be categorized into four groups:

• Incorrect agreements and/or conventions
• Mix-up of patient data in medical records
• No resuscitation statement or referral in place

• The wrong dose of prescription indicated  
• Wrong medication supplied 
• Incomplete or incorrect medication hand-over conducted.

• Delayed/incorrect examination results 
• Incorrect examination application 
• Digression from protocols and working agreements

• Admission and discharge communication issues 
• Miscommunication 
• Improper treatment

Improve patient safety

System-wide incident reporting visualizes the risks in the integrated care chain and supplies important operational control information. Reported incidents can vary in terms of content but they do provide insight into the weaker links within the integrated care chain (see text box). Targeted improvements can be made by anticipating and interpreting the value of this information.

>> Check our roadmap on how to improve patient safety.

During a four-month trial within a system-wide integrated care chain, no fewer than 33 adverse events and near misses were reported. The conclusion drawn was that care professionals are prepared to report incidents in the assumption that the reported incidents are but the tip of the iceberg. The trial was therefore expanded into a system-wide incident reporting project with the objective of:

• Reporting and registering undesirable events in the system-wide integrated care process;
• Analyzing incidents, whereby the root causes of the incidents are determined;
• Formulating improvement measures as required and if possible;
• Providing feedback related to the analyses and improvement measures to the reporting party.

The trial indicated that most incidents result from miscommunication in the hand-over between the care provider partners. For example, a general practitioner who receives the discharge notification about a patient, but only during the home visit does it become apparent that the patient has not been discharged, but passed away.

"System-wide incident reporting leads to a greater understanding of each other's work and healthcare improvements".

The network appointed a Committee for System-wide Incident Reporting, comprising general practitioners, pharmacists, hospital medical staff and a hospital safety consultant. All incoming incidents reported were analyzed by the committee. An assessment was then made as to whether improvement measures should be implemented. The network came to the conclusion that system-wide incident reporting did indeed lead to healthcare improvements. In addition, care professionals developed a greater understanding of each other’s work: an important precondition for safety enhancements. These promising experiences encouraged other institutions to reach out to and team up with the network.

System-wide incident reporting with TPSC Cloud™

TPSC Cloud™ is a Quality & Risk Management System that facilitates system-wide incident reporting. Incoming notifications are easily shared with committee members with the help of integrated e-mail functionality. The effectiveness of subsequent improvement measures is communicated in exactly the same way to not only committee members, but also to the incident reporter.

Moreover, with the help of various analytical methodologies such as the Fishbone Diagram, PRISMA or the HFMEA, the root causes of incident origin can be put on the radar screen. Weaknesses in existing processes are revealed, whereby risks for both patients and professionals in the system-wide integrated care chain are reduced while, at the same time, quality is boosted.

Like to learn more bout incident reporting and analysis? Download the Incident Management eBook.