What is an incident?

An incident can be any anything, which can result in any harm or has the potential to cause harm to a patient, staff or visitors.

The incidents reported are classified into:

• Near Miss Events
• No Harm Events
• Adverse Events
• Sentinel Events

Near miss events

“ A near miss” or “close call” is a serious error or mishap that has the potential to cause an adverse event but fails to do so by chance or because it was intercepted. It is assumed (though not proven) that the failures of the underlying system for near misses are the same as for actual adverse events. Therefore, understanding their causes should lead to systems design changes that will improve safety. A key advantage of a near-miss reporting system is that because there has been no harm the reporter is not at risk of blame or litigation.

No harm events

The error is not recognized and the deed is done but fortunately for the healthcare professional, the expected adverse event does not occur.

Adverse events

It can be any event or circumstance arising during patient care that could have or did lead to unintended or unexpected harm, loss or damage. An adverse event can happen due to an error and also without an error

An adverse event without an error can be classified as Adverse drug reaction, adverse anaesthesia reaction, adverse transfusion reaction

Sentinel event

Sentinel event is a relatively infrequent, unexpected incident, related to system or process deficiencies, which leads to death or major and enduring loss of function for a recipient of health services.

Major and enduring loss of function refers to sensory, motor, physiological, or psychological impairment not present at the time services were sought or begun. The impairment lasts for a minimum period of two weeks and is not related to an underlying condition.

Reporting an incident

“Incident Reporting Form” is made available in all the departments, in which incidents can be reported with all the details.

An “Incident Reporting Register” is also made available in the quality department so that the other incidents can be reported immediately by the staff.

Any employee can send an email to quality@manavatacancercentre.com describing the incident.

Incident can also be reported over the telephone, in case the reporter finds it difficult to comprehend. The extension number of Quality Improvement Team or the speed dial of the team members and Safety Officer can be used for this purpose.

Root cause analysis

Any major, infrequent incidents thus reported are analysed to find out the root cause/s. Finding out the root cause enables to take preventive action to avoid the recurrence of the incident.

“Root Cause Analysis is a structured investigation that aims to identify the true cause of a problem, and the actions necessary to eliminate it”

A Root Cause Analysis looks at the core principles behind an incident and asks:

• What happened?
• Why did it happen?
• How did it happen?
• What can be done to prevent/reduce it happening again?

After an incident occurs, it is graded to ascertain how serious the incident was. The first step is to collect a description of events from those involved and the environment in which they were working. This may take the form of:

• Information received from personnel (written or oral)
• Policies and procedures relating to the incident
• Patient’s records

Thus RCA is primarily done by the Quality Improvement Team with the help of concerned personnel and corrective and preventive actions are taken with the responsibility and timelines established.