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Background
Quality Indicators: Patient Experience
   • Overall patient satisfaction
   • Areas of higher and lower
      satisfaction
Quality Indicators: Patient Safety
   • Surgical Safety Checklist
   • Venous Thromboembolism
      Prevention
   • Pressure Ulcer Prevention
   • Ventilator-associated pneumonia
   • Total reported incidents and
      accidents
   • Reported Medication Errors
   • Reported Patient Falls
Learning from our mistakes
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Total Reported Incidents and Accidents

Adverse Events

The Jewish General Hospital (JGH) is strongly committed to reducing the number of adverse events—whether slight or serious— by improving the conditions where the potential for these events may exist.

Although we live in an imperfect world where accidents are bound to happen, it does not mean accepting it—especially in health care, where a seemingly minor oversight might end up having serious consequences.

 

Not only is eliminating adverse events a reasonable goal, it’s the law. Preventing, reporting and dealing with incidents and accidents is a requirement of Quebec’s Ministry of Health and Social Services (as outlined in Bill 113, 2002, S-4.2, chapter 71).

Also worth noting is that Canada-wide rates of incidents and accidents—and, therefore, the need to reduce these numbers—is backed up by solid research. In a pivotal article in the May 25, 2004, issue of the Journal of the Canadian Medical Association, a team headed by Dr. G. Ross Baker reported the results of the first Canadian study to provide a reliable estimate of adverse events in a wide range of hospitals across the country.

The study found that approximately 7.5 per cent of all patients who were admitted to acute-care hospitals in Canada in 2000 experienced one or more adverse events. Of those who experienced adverse events, nearly 37 per cent were involved in preventable adverse events, including deaths. According to the article, the study "suggests that of the almost 2.5 million annual hospital admissions in Canada similar to the type studied, about 185,000 are associated with an adverse event and close to 70,000 of these are potentially preventable."

Generally speaking, the same is true at the provincial level. In September, 2004, a research team led by Dr. Régis Blais reported a 5.6-per-cent rate of adverse events in Quebec hospitals. Here, too, a significant number of deaths and other adverse events could have been prevented. "A concerted effort must be made by health authorities, institutional managers and providers of care to implement measures that would enable the number of adverse incidents to be reduced, thereby improving the safety of patients," the study concluded.

The Baker and Blais studies provide us with very useful insight into preventable adverse events within Canadian and Quebec hospitals. However, it is important to note that the rates of adverse events determined through a chart review process as in the Baker and Blais studies cannot be compared to data compiled from employee reporting of incidents and accidents on a reporting form. Like other Quebec hospitals, the JGH collects data by completing the Quebec Health Ministry’s AH-223 incident/accident reporting form. Until recently, this information was not generally shared with the public; public reporting of adverse events is a new development for Quebec. Each healthcare organization is different, with varying volumes, populations served and complexities of cases. For this reason, the Jewish General Hospital’s approach to incidents and accidents reporting is to compare its performance to itself over time. This is directly in line with the viewpoint of the Ministry of Health and Social Services.

The number of reported incidents and accidents is therefore examined at the JGH in relation to the overall volume of activity and complexity of cases. Table 1 outlines the volume of activity.

Table 1: The volume of activity at the Jewish General Hospital

 Volume of Activity  2011-12 2012-13 2013-14
Total number of admissions (including newborns) 24,018  23,64623,853
Total number of emergency visits 72,987  72,38175,592
Total number of outpatient visits (including emergency visits) 687,359  686,568693,026
Total number of operations 13,651  11,75811,656
Total number of radiology examinations 189,716  187,405191,243
Total number of perscriptions processed 692,670  769,3831,002,733

Incidents and Accidents Reported by Type

The JGH takes note of a wide range of adverse events—everything from falls and medication errors (which have a direct and obvious effect on patients) to water spills, fires and thefts (which may or may not affect patients directly). In general, the types of events that staff report most often are falls, medication errors, and errors related to diagnostic tests (see Table 2).

Table 2: Reported incidents / accidents by type

   2010-2011 2011-2012  2012-2013
Falls (indicator) 871 905  929
Medication (indicator) 1804 2114  2213
Treatment 258 325 453
Diagnostic Tests 884 918 1148
Diet 128 101  115
Related to Materials 230 318 241
Related to Equipment 205 247  207
Related to Building 98 76  75
Personal Effects 144 161  193
Abuse Agression Harassment 558 533  815
Transfusional 70 74  93
Other 897 1057  975
Undetermined 0 0  0
 Total 6147  6829  7454
     
         
While patients are the primary focus of the JGH’s attention, the hospital’s incident/accident reporting system also keeps track of adverse events involving patients’ relatives, visitors, volunteers and students.

Categories of adverse events

There are a great many types of adverse events, with seriousness ranging from minor to severe. For ease of comparison, these events are grouped into categories in a special chart (shown below), whose two broadest classifications are "incidents" and "accidents".

An incident is an action or situation that has not affected anyone’s health or well-being, but might have caused harm if it had not been spotted and corrected in time—e.g., water spilled on the floor of a corridor.

An accident is a more serious action or situation with two types of consequences. The first is where healthcare staff must make an unplanned intervention in the patient’s care to ensure that no harm has occurred or will occur—e.g., after a patient falls and is assessed for injury, no injury is found, but the patient’s condition is monitored more frequently. The second is where harm or injury actually occurs—e.g., a patient receives the wrong dose of medication which causes unwanted drowsiness.

Incidents and accidents are sub-divided by severity (see Table 3). Included in the table below is the total number of incidents and accidents in each of the 10 categories of severity.

Table 3:  Reports of incidents and accidents at the JGH

Reports of incidents and accidents* at the JGH

(Categorized by severity)

Type of event

Result

Severity

2010-2011

2011-2012

2012-2013

Incident

No consequences

A: Circumstances existed, or events occurred, in which there was potential for error or damage (i.e., hazardous situations).

179

316

386

B: An error actually occurred, but its consequences did not reach anyone.

1220

1221

1464

Accident

Inconveniences or minor consequences

C: An error (including an error of omission) reached someone, but it did not affect that person. No additional monitoring or intervention was needed.

490

755

833

D: An error reached someone. Afterwards, monitoring was needed to confirm that the error had not affected that person and/or intervention was needed to ensure that the error would not affect that person later.

2472

2498

2724

E1: An accident occurred that may have contributed to, or resulted in, temporary consequences to someone. As a result, that person was given non‑specialized first aid.

492

522

470

Specialized care or longer hospitalization was needed

E2: An accident occurred that may have contributed to, or resulted in, temporary consequences to someone. As a result, that person was given supplementary specialized care or treatment. However, prolonged hospitalization was not needed.

1144

1385

1400

F: An accident occurred that may have contributed  to, or resulted in, temporary consequences to someone. As a result, that person was given supplementary specialized care or treatment. This involved admitting that person to the hospital or prolonging the hospitalization of that patient.

125

110

168

Sentinel event

G: An accident occurred that may have contributed to, or resulted in, permanent consequences to someone.

6

4

2

H: An accident occurred requiring intervention—e.g., cardio-pulmonary resuscitation (CPR)—that was necessary to sustain life.

16

17

6

I: An accident occurred that may have contributed to, or resulted in, someone’s death.

3

1

1

Total 

6147

6829

7454

 

* Please note: The figures in this chart do not include work-related accident by employees, which are reported to JGH Employee Health Services.

Even though hospital employees are increasingly willing to submit official reports about the incidents and accidents that they observe or are involved in, incidents and accidents are generally under-reported. This conclusion is confirmed by the scientific literature, which states that only a small percentage of adverse events are actually reported by hospital staff. Therefore, the work that the JGH undertakes in making improvements will be focused on encouraging staff to report more diligently and on preventing incidents and accidents from occurring in the future.

The JGH’s "no blame, no shame" policy

The JGH has a "no blame, no shame" policy, which is now an integral part of the hospital’s corporate culture. This policy will continue to be reinforced among all staff in an effort to increase the reporting of incidents and accidents over time. Employees are aware that if an incident or accident occurs, fingers will not be pointed when a report is filed. Rather, the JGH focuses on the information itself, which is used to help prevent another adverse event.

Staff reporting of incidents and accidents: An opportunity for improvement

As a result of the incidents and accidents that are documented at the JGH, steps are being taken to minimize or eliminate the possibility that similar incidents or accidents will happen again. For example, this could include anything from implementing a small-scale improvement to launching a broad-based analysis of root causes on a regular basis. The more reports are filed, the better informed the JGH is; the better informed the JGH is, the better prepared it is to keep problems from arising in the first place.

When a relatively minor incident occurs—for instance, a water spill—it can be rectified with a fairly simple solution, such as advising employees in the immediate area to be careful to avoid spills. However, when an accident happens and someone is harmed, a broader, more assertive response is needed.

When an accident requires the affected person to undergo treatment (anything from first aid to prolonged hospitalization), senior managers and clinicians must closely examine the way their department operates. After consulting with their employees and with doctors, nurses, pharmacists and other hospital personnel, they implement any changes that they feel are necessary to prevent a similar accident from recurring.

Instances where the degree of harm is most severe—up to and including death—are known as Sentinel Events. A full multi-disciplinary analysis of incidents and accidents is conducted on a regular basis by the Quality Improvement Teams of the hospital and is shared with staff. Whenever such an accident of category G, H or I takes place, the JGH launches a Sentinel Event Review, in which designated members of staff investigate the event and recommend ways of preventing a recurrence of the event. This investigation is given a very high priority. The Sentinel Event Review Report—along with a list of recommendations or newly implemented procedures to prevent a recurrence—is submitted to the hospital’s Quality and Risk Management Committee, to the Executive Director and to the Board of Directors.

In some cases, a Sentinel Event may also result in the creation of a type of in-house task force known as a Quality Improvement Team. This team can use the Sentinel Event as a springboard for a wider view of hospital-wide activities. For example, if a Sentinel Event occurred because of how a certain type of medication was administered in a specific department, the Quality Improvement Team might look at how that drug is administered throughout the hospital. The team would then recommend hospital-wide improvements in how that drug is administered.

Here is a description of some of the ways in which the JGH has learned from its mistakes by implementing improvements

It should be noted that the JGH also has more than 20 Quality Improvement Teams that conduct ongoing work to prevent various types of incidents and accidents.

Not only does the JGH give a high priority to investigating and preventing incidents and accidents, it places major emphasis on communicating with patients and their families about adverse events. This is a key element in the Disclosure pamphlet, which is available throughout the hospital and can be viewed by clicking on the graphic below.


JGH Disclosure Pamphlet