Did you know that a patient in the midst of a cardiac catheterisation process can be seen by as many as 99 care professionals while in hospital? This considerably increases the risk of incidents, or even worse, calamities.
It is important to report incidents large and small to learn how they originate. Not so much with the intention of pointing the finger (blaming and shaming), but to learn from the incident and prevent it happening again.
This blog describes what is needed to learn from incidents and calamities and how calamity and incident disclosure can contribute to healthcare improvement.
Incident and calamity disclosure
“The willingness to learn from each other’s mistakes and critical self- reflection are important preconditions for a safer health system”.
Incident Disclosure – being open and upfront about a medical incident – is receiving increasing international attention. In Amsterdam, for example, the International Disclosure Congress was organised on October 20th and 21st last year. Speakers from home and abroad were invited to share their experience about the day-to-day reality of incident reporting. The practical and strategic steps that a healthcare provider needs to take when disclosing a medical incident were also on the agenda.
“Sharing calamities is a powerful tool because care professionals realise this could potentially happen to them too, in their own medical institution”.
Disclosure is more than simply informing patients, their family and/or those bereaved; it is also informing the general public. The healthcare provider must disclose what is being and will be done to prevent a similar incident occurring in the future.
Sharing lessons learned
The public disclosure of calamities is an important step in the improvement of the healthcare system. Care professionals can benefit from each other’s experience in the form of lessons learned. It goes without saying that death resulting from a calamity is tragic. Patients and clients must be able to rely on good, safe, healthcare.
“Lessons learned are still not always shared with other departments. The result: silo solutions, with the risk that colleagues on another department can still be responsible for causing the same incidents”.
What goes for calamities is equally valid for incidents. The scope of incident analysis by safety commissions often goes no further than the institution or department itself. The commission analyses the reported incident and advises the Management Board on how best to respond. Care professionals have insufficient insight into the methodology employed by the commission and the consequences of the reported incident. This benefits neither incident transparency nor the willingness by caregivers to report an incident.
Realize continuous improvement
Incident reporting offers insight into the weaker links of a healthcare process. But the root cause of an incident does not immediately become apparent, simply because it has been reported. This calls for comprehensive analysis.
However, it appears that medical institutions waste opportunities in the field of cyclical analysis and continuous healthcare improvement. Now that not only adverse events but also near misses are reported, the number of notifications has increased substantially in recent years.
The vast majority of incidents reported are classified as low risk (to be compared with the airline industry >95% is low risk). There is simply no sense of urgency to analyse this kind of reported incidents. Time pressure often contributes to the fact that – following registration – the commission takes reported incidents of this nature no further. The opportunity for continuous healthcare improvement is thereby wasted.
From registration to optimization
Incident management is about gaining insight into the most significant risks and the opportunities to anticipate their occurrence. It is an important driver of the Risk Management System, because it puts the safety record of the healthcare provider on the radar screen.
The day-to-day reality would suggest that incident management still faces considerable challenges, including;
- Silo solutions (knowledge is often not shared with other departments).
- Incident reporting often goes no further than simply registration. Analysis and optimisation of the cyclical improvement process are too often not part of the process.
- Complexity and variety of incidents.
- Continuously changing legislation and regulations.
- Pressure to complete administrative processes correctly and on time.
No uniformity in the manner of registration; mostly, manual and traditional methods are employed that can cause mistakes to be made and are not clear to one and all.
Medical institutions still have some way to go down the road to healthcare optimisation with an improvement cycle that truly contributes to the enhancement of patient safety.
There are opportunities to be grasped, particularly in the field of cyclical analysis that facilitates continuous improvement throughout the health system.
Like to know more about optimisation of healthcare processes? Download our E-book 'Incident Management, In search of continuous healthcare improvement':
Wendy Rientjes, 26 November 2016
IGZ. (2016, August 28). Openheid over calamiteiten onderwerpen van gesprek in de zorg. Retrieved from https://www.igz.nl/actueel/nieuws/openheid-over-calamiteiten-onderwerp-van-gesp.aspx
Laarman, B. S., & Akkermans, A. J. (2016, September 29). Ervaringen in binnen- en buitenland Congres over openheid na medische incidenten. Retrieved from http://www.overkwaliteitvanzorg.nl/2016/09/ervaringen-binnen-en-buitenland-congrs-openheid-medische-incidenten/
Zorgvisie. (2016, October 25). ‘Ziekenhuizen kunnen meer leren van calamiteiten ’. Retrieved from https://www.zorgvisie.nl/Kwaliteit/Verdieping/2016/10/Wagner-Ziekenhuizen-kunnen-meer-leren-van-calamiteiten/