Quality in Medical Care Section

Patient Safety Unit

INCIDENT
REPORTING &
LEARNING FROM
ERROR
Patient Safety Unit
Quality in Medical Care Section

Ministry of Health Malaysia

@ Secretariat, Patient Safety Council Malaysia

In Collaboration with :

Patient Safety Module Technical Committee

 LEARNING

Quality in Medical Care Section

Patient Safety Unit
OBJECTIVES
• Understand the basic concept of incident
reporting of patient safety and learning
systems.
• Understand the differences between
error, violation, and near-miss incidents.
• Understand the importance of correct
patient identification
• Understand the role of Junior Health
Care Professionals in improving Patient
Safety through incident reporting and
learning systems.
INTRODUCTION

Quality in Medical Care Section

Patient Safety Unit
Patient Safety:
The reduction of risk of unnecessary harm associated
with healthcare to an acceptable minimum; Absence
of preventable harm to a patient during the process
of healthcare.

Patient safety incident:

An event or circumstance which could have resulted,
or did result, in unnecessary harm to a patient. An
incident can be a reportable circumstance, near miss,
no harm incident, or harmful incident (adverse
event).
 PATIENT SAFETY

Quality in Medical Care Section

Patient Safety Unit
1 in 10 patients is harmed while receiving hospital care
( Estimation in developed country ) -W.H.O

Malaysia Hospital admissions in 2013 3,323,024

Estimated adverse events (10%) 332,302
 Quality in Medical Care Section
Patient Safety Unit
PATIENT SAFETY
Medical error is the third leading cause of
death in the United States which accounts
for 10% of all US death
Makary et al., BMJ, pg. 353; May 2016
10%
Patient Safety Unit
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Examples of Patient Safety Incidents

INCORRECT SPECIMEN
MEDICATION ERROR LABELING
POOR HANDWRITING  WRONG PATIENT
 INCORRECT DOSE
 UNAWARE OF PATIENT ALLERGY

WRONG SURGERY /
TRANSFUSION ERROR PROCEDURE
 WRONG PATIENT / SITE / SIDE
 Quality in Medical Care Section
Patient Safety Unit
Examples of Patient Safety Incidents

INFANT DISCHARGE TO
PATIENT FALL
NOT AWARE OF FALL RISK THE WRONG PERSON
WRONG PATIENT
INJURY TO NEONATE POST
IDENTIFICATION
DELIVERY
( SWITCHED PATIENT TAG) ERB PALSY
SHOULDER DYSTOCIA – NOT
RETAINED FOREIGN
AWARE OF RED FLAGS AND
BODY UNASSISTED
E.g. POST PARTUM ( TAMPOON BEWARE!!
/ GAUZE ) IT COULD HAPPEN TO
ANY PATIENT UNDER
YOUR CARE!
TYPES OF PATIENT’S SAFETY INCIDENT

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Patient Safety Unit
PATIENT SAFETY
NO HARM
INCIDENTS
EVENT REACHED PATIENT
BUT NO DISCERNABLE
ERROR HARM RESULTED
VIOLATION

NON – INTENTIONAL INTENTIONAL DEVIATION

NEAR MISS
DEVIATION FROM AN FROM AN ACCEPTED
ACCEPTED PROTOCOL OR PROTOCOL OR STANDARD AN ERROR THAT HAS
STANDARD OF CARE. OF CARE. BEEN PREVENTED BEFORE
IT OCCURRED
“TAK SENGAJA” AGAINST THE LAW
 TYPES OF PATIENT’S SAFETY INCIDENT

Quality in Medical Care Section

Patient Safety Unit
ERROR VIOLATION NEAR MISS

ACCIDENTALLY wrote Take blood pre- and post- Wrong dose of medication
wrong unit on medication potassium correction but being prescribed but
prescription send the same sample DETECTED BEFORE IT IS
e.g : 10mg instead of 10µg INTENTIONALLY ADMINISTERED
( pre-sample ) twice and to the patient
resulting in over-
correction
10
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Patient Safety Unit
PATIENT IDENTIFICATION
Patient identifier: Person specific information that can be used to identify
specific patient among other patients. (G6)

Minimum of 2 identifiers need to be used!

1. FULL NAME
2. IDENTIFICATION NUMBER
3. DATE OF BIRTH
4. ADMISSION NUMBER
5. ADDRESS
UNACCEPTABLE METHODS

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Patient Safety Unit
OF IDENTIFICATION

ROOM NUMBER
BED NUMBER

DIAGNOSIS

TYPE OF PROCEDURE

HOW TO IDENTIFY PATIENT?
1. Ask patient to state their name
(identifier 1) - open ended questions
2. Ask patient to state their unique
number (identification card or
registration number or date of birth)
(identifier 2)
3. Check these details against the
wristband and their medical record
(cross reference)
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Patient Safety Unit
DROWSY/ SEDATED/ UNCONSCIOUS/
PAEDS PATIENTS?
1. Refer to the identity wristband/
identification card
2. Verify the details with a relative or
caretaker
IF RELATIVE IS NOT AVAILABLE?
1. Refer to the identity wristband
2. 2 clinical staffs have to check and
confirm the identification in the patient’s
clinical record and document it.

TWO IDENTIFIERS MUST BE CONFIRMED PRIOR TO any
procedures / tasks
• Placing or replacing
wristband/bracelet
• Upon Admission
• Transferring / transporting a patient
to other care setting
• Performing any diagnostic test
• Obtaining blood sample or other
specimen
• Prescribing medicine &
administration of medicine
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Patient Safety Unit
• Transfusion of blood or blood
product
• X-Ray or imaging procedure
• Any invasive / non-invasive
procedures eg CBD / NGT insertion
• Giving lab results / results of
diagnostic test
• Discharging a patient
• Confirmation of death

DO NOT...
1. Do not read patients detail to
them and allow them to
passively agree with you
2. Do not take blood from a patient
without checking details against
fully completed request form
3. Do not label sample container
before taking blood / sample.
You may get distracted before
you completed the task.
Quality in Medical Care Section
Patient Safety Unit
4. Do not perform two tasks at
the same time
eg : taking blood from several
patients and labeling afterwards
5. Do not performed the task
remotely from the patient
eg : label blood container &
request form not at patient
bedside
Patient Safety Unit
Quality in Medical Care Section
AN INCIDENT?
REPORT
HOW TO

G7
WHAT IS INCIDENT REPORTING

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Patient Safety Unit
& LEARNING SYSTEM?
• It is a system of reporting patient safety incidents that happen in
healthcare, investigate or review why the incident happened, learn
from the incident, take appropriate action to prevent similar incidents
from happening, and share with others.
• It involves “holistic improvement of the system” and not about “finding
an individual to be blamed”.
• 3 MAIN ELEMENTS OF INCIDENT REPORTING
“Report + Respond + Share = Incident Reporting & Learning System”
 Quality in Medical Care Section
Patient Safety Unit
WHY SHOULD YOU REPORT IT?

DAMAGE CONTROL IMPROVE QUALITY & SAFETY

PREVENT WORSENING OF
LEARNING FROM
MISTAKES OF HEALTHCARE
SITUATION IMPROVE SYSTEM DEFECT
 Quality in Medical Care Section
Patient Safety Unit
I.R 2.0 FORM

SECTION A:
FILLED BY H.O WHO
IS INVOLVED /
WITNESS THE
INCIDENT

20
Patient Safety Unit
Quality in Medical Care Section
ANY INCIDENTS RELATED TO PATIENT SAFETY!
 Action to Take as a

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Patient Safety Unit
Junior Health Care Professional

PATIENT SAFETY INCIDENT OCCUR

IMMEDIATE CORRECTIVE MEASURE/

1 DAMAGE CONTROL

INFORM SUPERIOR
AS A JUNIOR
HEALTH CARE 2 ( e.g. MO , Specialist or other available
PROFESSIONAL experienced officer )
 Action to Take as a

Quality in Medical Care Section

Patient Safety Unit
Junior Health Care Professional
PATIENT SAFETY INCIDENT OCCUR

FILL IN FORM I.R 2.0 ( AS WITNESS /

3 PERSON INVOLVED )

The incident will be investigated and

AS A JUNIOR
HEALTH CARE action will be taken to prevent further
PROFESSIONAL occurrence of the incident.
 Overview of Incident Reporting

Quality in Medical Care Section

Patient Safety Unit
INCIDENT
MONITORING OF ACTION
OCCUR
PLAN

IMMEDIATE ACTION /
DAMAGE CONTROL
ACTION TAKEN & FURTHER
OCCURANCE OF INCIDENCE
PREVENTED

INFORM SUPERVISOR
INCIDENT INVESTIGATED FILL IN INCIDENT
BY INVESTIGATION TEAM REPORTING FORM
(e.g : Root Cause Analysis) (SECTION A)
 Examples of Improvement Achieved

Quality in Medical Care Section

Patient Safety Unit
Through The Incident Reporting System
1 PROBLEM IMPROVEMENT

WRONG SURGERY • SAFE SURGERY SAVES

( DONE ON WRONG LIVES PROGRAM
PATIENT/ SITE / SIDE ) • SSSL CHECKLIST
SAFE SURGERY SAVES LIVES
PROGRAM
SSSL CHECKLIST
 Examples of Improvement Achieved

Quality in Medical Care Section

Patient Safety Unit
Through The Incident Reporting System
2 PROBLEM IMPROVEMENT

• USAGE OF STICKER TO
BCG VACCINE
INDICATE BABIES THAT
MISTAKENLY INJECTED
HAD RECEIVED THEIR
TWICE TO BABY IN NICU
VACCINATION
USAGE OF STICKER TO INDICATE
BABIES THAT HAD RECEIVED THEIR
VACCINATION
 Quality in Medical Care Section
Patient Safety Unit
Examples of Improvement Achieved
Through The Incident Reporting System
3 PROBLEM IMPROVEMENT

• USAGE OF ULTRALOW
GERIATRIC PATIENT HOSPITAL BEDS FOR
FALLING FROM NORMAL GERIATRIC PATIENT
HOSPITAL BED • PATIENT FALL
PRECAUTIONS USAGE OF ULTRALOW
HOSPITAL BEDS FOR
GERIATRIC PATIENT
 Quality in Medical Care Section
Patient Safety Unit
Take Home Message

We need to take action to improve and prevent similar incidents

from happening again
Let TWO IDENTIFIER be our routine caily practices, as what we do
habitually is what we do in a hurry
Incident reporting is not just about “paperwork”, the aim is to
improve our system and as a Junior Health Care Professional, you can
play an important role in improving our system.
Patient Safety Unit
Quality in Medical Care Section
REMEMBER
AND
Patient Safety Unit
Quality in Medical Care Section
DON’T HIDE IT
REPORT IT!
Patient Safety Unit
Quality in Medical Care Section
YOU
Prepared by Dr. Umi Salwa Binti Mohd Kamal