DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20160516

Patient safety with reference to the occurrence of adverse events in admitted patients on the basis of incident reporting in a tertiary care hospital in North India

Moonis Mirza, Farooq A. Jan, Rauf Ahmad Wani, Fayaz Ahmad Sofi

Abstract


Background: A good quality report should lend itself for detailed analysis of the chain of events that lead to the incident. This knowledge can then be used to consider what interventions, and at what level in the chain, can prevent the incident from occurring again. Aim was to study the occurrence of adverse events on the basis of incident reporting.

Methods: Critical analysis of incident reporting of adverse events taking place in admitted patients for one year by using WHO Structured questionnaire on patient safety (RF-1 & RF-2 forms) along with their record review and interview to the concerned staff.

Results: 253 incidents of adverse events were reported during the study period of one year. Most common screening criteria being, Patient/family dissatisfaction with care received, documented or expressed during the current (221 incidents i.e. 87.35%), followed by hospital acquired infection/sepsis (29 incidents i.e. 11.46%). 13 incidents (5.13%) were reported for unexpected deaths due to adverse events. 38.9% of reported adverse events studied showed signs of health care team responsible for causing adverse events. 39% of adverse events were found preventable and 61% of adverse event was found non-preventable.

Conclusions: Incident reporting of adverse events should be encouraged in all hospitals.

 

 


Keywords


Incident reporting, Adverse events, Patient safety, Preventable

Full Text:

PDF

References


Wilson R M, Michel P, Olsen S, Gibberd R W, VincentC, El-Assady R et al. Patient safety in developing countries: retrospective estimation of scale and nature of harm to patients in hospital. BMJ. 2012;344:e832.

Smith AF et al. Patient safety: people, systems and techniques. Acta Anaesthesiol Scand 2007;51:51–3.

R. P. Mahajan et al. Critical incident reporting and learning; British J Anaesthesia. 2010;105(1):69-75.

Nuckols TK, Bell DS, Liu H, Paddock SM, Hilborne LH. Rates and types of events reported to established incident reporting systems in two US hospitals. Qual Saf Health Care. 2007;16:164-8.

Arabi, Yaseen, Alamry, Ahmed, Al Owais, Souzan et al. Incident reporting at a tertiary care hospital in Saudi Arabia. J Patient Safety. 2012;8(2):81-7.

Vincent C, Stanhope N, Crowley-Murphy M. Reasons for not reporting adverse incidents: an empirical study. J Eval Clin Pract. 1999;5(1):13-21.

Evans SM, Smith BJ, Esterman A, Runciman WB, Maddern G, Stead K et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Health Care. 2007;16:169-75.

Lin CC, Shih CL, Liao HH, Wung CH. Learning from Taiwan patient-safety reporting system. Int J Med Inform. 2012;81(12):834-41.

Öhrn A, Elfström, J, Liedgren, C, Rutberg, H. Reporting of sentinel events in Swedish hospitals: comparison of severe adverse events reported by patients and providers. Joint Commission J Quality and Patient Safety. 2011;37:495-501.

Ethan JR, David L, Stephen PG, Sanjaya K, Jack C, Deeb SN. Does Error and Adverse Event Reporting by Physicians and Nurses Differ? Joint Commission J Qual Patient Safety. 2008;34(9):537-45.

Harris CB, Krauss MJ, Coopersmith CM, Avidan M, Nast PA, Kollef MH et al. Patient safety event reporting in critical care: a study of three intensive care units. Crit Care Med. 2007;35(4):1068-76.