It's time to pay more attention to incident reporting and analysis.
Quality incident reporting lies at the heart of many initiatives to improve patient safety. Risk management and patient safety programs rely on incident reporting to provide data on the nature of safety problems and to provide indications of their causes and potential solutions.
Increased Prominence of Incident Reporting
In the United States, the Agency for Healthcare Research and Quality (AHRQ) made incident reporting the centerpiece of its first patient safety funding program, investing $25 million in the first year into researching incident reporting systems. The UK National Patient Safety Agency (NPSA) has recently launched a national reporting and learning system following substantial piloting and testing across the National Health Service (NHS).
Incident reporting provides several important functions in healthcare:
- Documenting information about an event shortly after it occurs
- Assisting investigations of probable causative factors
- Helping to determine preventive measures
- Determining if and when performance deviates from standard procedures
- Providing data for statistical analysis for the Quality Assurance Committee/Safety Committee
- Assisting with litigation investigations
Adverse outcomes for residents are difficult and sometimes traumatic for everyone concerned. Some incidents pose considerable challenges—especially repeat events. In the increasingly litigious environment in the long term care industry, it's important to identify frequent fallers (for example) and to be consistent in adjusting care plans across residents in all facilities. One unit in one facility that's out of sync can mean poor care planning and can result in hundreds of thousands of dollars of claims.
Incident Reporting Best Practices
An incident report should be completed when there's any unexpected event or “near miss” event. You should establish guidelines regarding:
- What events should be reported
- How quickly an incident report should be completed
- What elements belong in the report and what should be omitted (e.g., opinions)
- Legible handwriting
- Routing of the report
The incident report form should include a “check box response” to the extent possible to save time, standardize reporting, enhance later analysis, and help minimize extensive narrative writing that encourages opinions and drawn conclusions.
Some states allow confidentiality of information under the quality assessment and assurance process. Information contained on the incident report is deemed to be legally privileged communication and is “confidential.” Follow these practices:
- The purpose of the incident/accident report form is to track and trend data for potential action plans. It's an internal document and therefore must be marked “Confidential, Prepared for Quality Assurance and Peer Review Purposes.”
- Incident reports should not be duplicated, faxed, or placed in the medical record
- No mention of an incident report should be documented in the resident’s health record
Identify Risk Proactively
Changes in the healthcare industry, increased focus on resident safety awareness, and emphasis on implementing actions to decrease risk have made it more important than ever for healthcare providers to be proactive in identifying risk and taking preventive approaches to decrease risk.
The goal for healthcare providers is to provide the best quality of care possible, as well as continuous assessment and improvement of the quality of care rendered to the residents. It is essential to train staff on incident reporting policy and procedures, and to use the incident report data in the Quality Assurance Program to implement plans, improve outcomes and decrease potential risk.
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