In order to learn from incidents, it is important that all adverse events and near misses are reported. Unfortunately, this is often seen as an additional administrative step that is experienced as difficult and unnecessary. This blog describes the benefits of digital incident reporting and shows that an incident management system is not something only the larger healthcare institutions can afford.
Incident management in healthcare
“Before you can do anything about a mistake, you need to report it. And that’s where it goes wrong, instantly…”
In the professional practice of many care professionals, making mistakes is sometimes regarded as a given. In a manner of speaking, it is almost accepted that things occasionally go “wrong” and that what went wrong is not seen as a mistake. Let alone that the incident be reported; an additional administrative step that is viewed as irksome and surplus to requirements. The mistake has already been rectified, so why bother? Why register an incident that has been put right?
“If something impacts the core of your professional practice, it is difficult to exercise critical self-reflection.”
It becomes particularly complex when the mistake has a serious impact on the patient. Doctors are still trained with the notion that they as individuals are responsible for their errors. This makes it more difficult for doctors to report a mistake. Of course a doctor knows exactly how to act at patient level. But in order to learn from incidents, we have to look at the combination of events and circumstances. People make mistakes. But to prevent us making these mistakes, we need to design our environment in such a way that these mistakes cannot be made in the first place.
How to learn from incidents?
“In order to learn from adverse events, far more attention must be paid to the combination of circumstances.”
It is important that all adverse events and near misses are reported. Hospitals have been aware of this imperative for years, but now also pharmacists, general practitioners and midwives regard incident reporting more as a learning methodology. In the Netherlands, a reporting month in the dental health system has been announced with the aim of enhancing internal quality. The aim is to motivate and facilitate care professionals in incident reporting, because there is a lesson to be learned from each and every adverse event and near miss. This generates awareness amongst caregivers about the danger of putting patients in harm’s way. The caregiver is offered insight into what went wrong and the measures that have been implemented to ensure the incident does not happen again.
It is important to report all incidents. But reporting limited to simple registration is simply not enough. If incidents are not analysed, they are often and mistakenly brushed off as human error.
“The platform aims to compile a databank to flag and analyse trends, to discuss them and, by doing so, to mitigate the risk.”
Healthcare is much more complex than simply adhering to protocols. Digital incident reporting facilitates thorough insight into the root causes of the origin of incidents and the various types of incident. The content and type of a reported incident is registered without additional administrative steps needing to be undertaken. A substantial and valuable database is gradually built up over time thanks to the reporting of adverse events and near misses. Trends emerging from the database can be identified and relevant input can be derived from these trends. This in turn contributes to healthcare improvements.
“Thorough analysis of a few incidents is preferred to superficial registration of as many incidents as possible.”
Incident management system for small/single healthcare providers
The larger healthcare providers such as hospitals and mental care organisations have at their disposal an incident management system for the digital reporting and follow-up of adverse events and near misses. But how do you do that as a relatively small healthcare institution? For those healthcare providers, we found an innovative solution: Getting an advanced online Quality & Risk Management System, while realising opportunities for sharing resources and economies of scale and thus cost savings! The solution not only provides financial benefits, but also provides valuable advantages, like benchmarking possibilities and sharing lessons learned with others connected to the system. Our solution has proven to be effective among the nursing homes of New Brunswick.
Like to read more about incident reporting and continuous healthcare improvement? Download the Incident Management e-book.
Wendy Rientjes, 17 January 2017
Doeleman, A. (2014, August 21). Leren van incidenten. Retrieved from http://ntdigitaal.nl/content/leren-van-incidenten (“Learning from incidents”)
Stalenhoef, A. (2012, May). Voor incidenten melden is veiligheid nodig. Retrieved from https://www.henw.org/archief/volledig/id4935-voor-incidentmelding-is-veiligheid-nodig.html (“Safety is a prerequisite for incident reporting”)
Wisman, R. (2017, January 13). Leren van incidenten. Retrieved from https://www.artsenauto.nl/leren-van-incidenten/ (“Learning from incidents”)