Patient Safety Incident Reporting In Accident & Emergency
An article in Clinical Risk, a journal covering patient safety and medical law, has reported on a one year review of patient safety incident reporting in an accident and emergency department.
Studies have shown that 10% of patients admitted to hospital experience what is known as an adverse event and when multiple adverse events are included the figure rises to 11.8%.
Unfortunately, half of these are judged to be preventable and medication errors alone account for between 10 – 20% of adverse events in patients admitted to hospital, mainly amongst junior doctors.
Furthermore, a number of studies show that the majority of these errors go unreported. Doctors have been shown to be more reluctant to report adverse events whereas nurses are more likely to report their own errors.
Over the last 10 years an incident reporting system in hospitals has been developed in the UK. A body called the National Patient Safety Agency (NPSA) has been set up for the collation of errors at both local and national level.
A patient safety incident is defined as an unintended or unexpected incident that either could have or did lead to harm to one or more patients.
Until now no study has assessed the incidence of these medical errors in an emergency department. A study was, however, carried out by the emergency department at Mayday University Hospital. The results showed that in a 12 month period, 112,957 patients attended the department. During that period, 179 incident reports were completed. Interestingly, of these 179 reports, only 115 (64%) actually fell within the National Patient Safety Agency definition of a patient safety incident. This amounted to just over 0.1% of all attendances. However, only 9 of the incident forms indicated that the patient or their relative had been informed of the incident.
What was of interest was that of 115 reports that could strictly be classified as a patient safety incident (as opposed to injuries involving staff or non-patients), 102 (88.7%) were reported by nursing staff and only 13 (11.3%) were reported by clinicians.
4 events were linked to the death of the patient. These were all reported by clinicians and included misinterpretation of electro-cardiograms (ECGs) in 2 patients and 2 biochemistry results. The remaining 111 incidents were due to a number of different reasons to include transferring the patient, clinical assessment, infection control, medical equipment, medication and treatment provided. Of those that resulted in harm to the patient, none were deemed to have resulted in severe harm. In addition to the 4 events which were linked to a patient's death, a further 3 (all missed fractures) resulted in moderate harm with the remainder resulting in low harm or no harm. This group included missing notes and missed fractures.
What is of interest is that the study by Mayday Hospital shows that healthcare professionals, especially doctors, are reluctant to report adverse events. This might be because adverse events are a serious problem for the NHS with the estimated cost in extra bed days alone in the UK thought to amount to £1 billion per year.
It is to be hoped that all hospitals will eventually have a system in operation that will make sure that healthcare professionals receive regular feedback, both of the type and frequencies of errors that are reported along with information about system changes which are being made in response to those medical errors.
The authors of the study stated that senior clinicians can set an example by reporting errors and near misses which may help towards changing the culture around incident reporting so that this becomes an essential element in the provision of optimal patient care rather than trying to hide the errors which means that other patients are then put at risk.
Summary
It is clear from the figures and comments above that some errors still go unreported, so the true extent of them is not yet known. However, it is hoped that more accurate reporting will lead to improvements in monitoring and the implementation of more watertight systems to reduce the number of medical negligence claims currently made.
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