Incident / Near Miss Reporting

Karen Ting Hie Hee

Quality Management Specialist
RN, CPN, MW, BN . CPHQ
Objectives
• At the end of this presentation,
you will able to:
– Define Incident / Near Miss Reporting
– Understand purpose of Incident / Near
Miss Reporting
– Implement incident / near miss
reporting system
– Understand prerequisites for a
successful incident / near miss
reporting system
Definition

Incident
• Any unusual event or
circumstances that are not
consistent with the normal
operation of the facility or
outcome of a procedure.
Definition (cont.)

Near Miss
• An event or situation that could
have resulted in an Adverse Event
but did not, either by chance or
through timely intervention (VHA,
2002). A recurrence carries a
significant chance of a serious
adverse event and/or outcome.
Definition (cont.)

• Example of a Near Miss Call

•A surgical or other
procedure almost
performed on the wrong
patient due to lapses in
verification of patient
identification, but caught
at the last minute by
chance.
Definition (cont.)
• Sentinel Event
– An unexpected occurrence
involving death or serious physical
or psychological injury or the risk
thereof. Serious injury specifically
includes a limb or function. The
phrase “or risk thereof” includes
any process variation for which a
recurrence would carry a
significant chance of a serious
adverse outcome.
Definition (cont.)

Root Cause Analysis

• A process for identifying the
basic or contributing causal
factors that underlie variations
in performance
Purpose of Incident & Near
Miss Reporting
• To create a standardized
mechanism to identify, report,
investigate, resolve and trend
adverse events.

• To provide a record of patient

related events that will serve to
alert Risk Management Team to
potential negative patient
outcomes.
Purpose of Incident & Near
Miss Reporting (cont.)
• To provide a mechanism to alert
administration to actual or
potential safety hazards.

• To collect data and this allows the

analysis of trends that may identify
organizational, system, and
environmental problems.
Purpose of Incident & Near
Miss Reporting (cont.)

• To allow lessons to be learnt to

enable change and
improvements.

• To improve claims management

and legal outcomes.
Type of Reporting Form

• Near Miss Report should be

completed only when the
event/circumstance has not
impacted a patient.

• Incident Reporting Form should be

completed when a patient has
been effected.
Why Do We Complete an
Incident / Near Miss Report?

• Provide record of incident

• Document the facts
• Provide base from which staff can
further investigate
• Determine and evaluate
deviations & corrective actions
Incident / Near Miss
Reporting Process

Who Reports an Incident?

• Individual who has the best
knowledge
• Supervisor can assist in
completion
• Do not be afraid to report
• If in doubt, fill one out!
Incident / Near Miss
Reporting Process (cont.)

When Should an Incident / Near

Miss Report Be Completed?
• Immediately after discovery
• Delays cause facts to be less
clear
• Made in due course has most
legitimate value
Incident / Near Miss
Reporting Process (cont.)
What are the documentation
requirements?
• Complete all blanks
• Record facts
• Make objective statements
• Do not place blame
• Hearsay, opinion or assumption should
be on a separate sheet
• Patient statements - record as direct
quotations when possible
Incident / Near Miss
Reporting Process (cont.)

What are the charting

requirements?
• Medical record should only document
the incident/occurrence
• Make no reference in documentation
that an incident report is being
completed
• Never file an incident report in the
medical record
Incident / Near Miss
Reporting Process (cont.)
What are the requirements for
Equipment Related Incidents?
• Document name, manufacturer, control
number and other identification
• Suspected malfunction, document facts
relating to malfunction
• Remove equipment from service, secure
it for later testing
• Independent evaluation of equipment
Incident / Near Miss
Reporting Process (cont.)

When and Where should you

submit the incident / near miss
reporting form?
• Submit the Incident / Near Miss
Report to The Risk Management
Team within 72 working hours.
Incident / Near Miss
Reporting Process (cont.)

Who handles the reporting forms

within the Risk Management
Team?
• The Risk Management Specialist
or Quality Management Specialist
Incident / Near Miss
Reporting Process (cont.)

What is the procedure of

handling events that are
reported?
• The first step is to assign actual
and potential SAC scores that
then define what further actions
are necessary.
Incident / Near Miss
Reporting Process (cont.)
What are the types of actions?
• SAC 1 – Track & trend
• SAC 2 – Collaborate & coordinate with
HOD in investigating the event and
devising corrective/preventive actions.
• SAC 3 & Sentinel Event
– Inform Executive Medical Director
immediately
– Conduct root cause analysis as per
policy
Incident / Near Miss
Reporting Process (cont.)

Who manages the data?

• The Data Technician:
–Transcribes the information into
the incident / near miss
database
–Generates quarterly statistical
reports
Incident / Near Miss
Reporting Process (cont.)
Who is responsible for data
analysis?
• The Risk Management or Quality
Management Specialist:
– Performs analysis of aggregated
data.
– Makes recommendations
– Submits analysis report with
recommendations to the Risk
Management Team.
Incident / Near Miss
Reporting Process (cont.)

What are the responsibilities of

the Risk Management Team?
• The Risk Management Team
– Initiates improvement projects and
implements recommendations in
collaboration with process owners.
Incident / Near Miss
Reporting Process (cont.)
What are the responsibilities of the
Risk Management Team?
– Submit analysis report with
recommendations to Executive Medical
Director, Hospital Quality Improvement
Committee, Patient Safety Committee,
HODs, and Quality Improvement
Representatives/Designees
– Provide feedbacks to all employees via
quarterly newsletter
Incident / Near Miss
Reporting Process (cont.)
What are the responsibilities of the
Head of Department?
– Initiates improvement projects and
implements recommendations in
collaboration with the Risk Management
Team
– Provides feedback to the Risk
Management Team on implementation
and monitoring effectiveness of changes
and improvement plans.
 Establishing and
maintaining a successful
incident / near miss
reporting system is not an
easy task.
Making Incident / Near Miss
Reporting Work

• Provide induction training for all

employees on incident / near
miss reporting

• Provide continuing education on

the aims and importance of
incident / near miss reporting
Making Incident / Near Miss
Reporting Work (cont.)

• Provide a clear statement that all

members of staff, regardless of
profession and grade are
responsible for reporting.
• Define clearly reportable
incidents / near misses
Making Incident / Near Miss
Reporting Work (cont.)

• Use user friendly incident / near

miss reporting form
• Ensure clarity on how to report
• Encourage staff to report an
incident even if they are unsure
whether it is necessary to do so.
Making Incident / Near Miss
Reporting Work (cont.)
• Assign a designated person on shift
who is responsible for checking that
any incident occurring during that shift
is reported
• Devise a policy of confidential
reporting, no blame and no disciplinary
action except in cases of gross
misconduct, repeated errors despite
retraining, or criminal negligence
Making Incident / Near Miss
Reporting Work (cont.)

• Use Safety Assessment Code to

prioritize actions.

• Regular feedback to staff

regarding the action taken as a
result of their reports
Making Incident / Near Miss
Reporting Work (cont.)

• Design of corrective strategies to

reduce undesirable incidents in
the future

• Monitor effectiveness of change

and improvements
 Success of a system is
dependent on a change
of culture within the
organization, where staff
must be convinced of the
importance of safety.
Evaluate Your Reporting System

• Does the incident report capture all

essential data?
• Is there just culture & confidentiality
to the system?
• What are the steps to follow in
incident reporting?
• Is there a focal office for incident
review?
Evaluate Your Reporting
System (cont.)
• Do all staff use the form?
• What critical incidents are
important?
• What problems do you know about
now?
• What do you do about them?
• Does a systematic review process
exist whereby incidents are
reviewed?
Evaluate Your Reporting
System (cont.)
• How do you know what deficiencies
exist?
• Who receives this information?
• Who provides this information
• With whom is this information
shared?
• Has a committee been appointed to
review incidents?
References
• Alberts, C., & Dorofee, A. (2006). Advanced risk analysis for
high-performing organization. Retrieved June 1, 2008, from
www.sei.cmu.edu

• Joint Commission International, (2008). Joint Commission

International Accreditation Standards for Hospitals. Ilinosis:
Joint Commission Resources, Inc (JCR).

• Risk Management Program Development Tool kit. American

Society for Healthcare Risk Management of the American
Hospital Association (2001).

• Veterans Health Administration (2002). VHA NATIONAL

PATIENT SAFETY IMPROVEMENT HANDBOOK. Retrieved
June 1, 2008 from http://www.va.gov/NCPS/Pubs/NCPShb.pdf

• Vincent, C. (2001). Clinical risk management: Enhancing

patient safety (2nd ed.). London: BMJ.