Healthcare Waste Management Conference in Africa Today

Incident Reporting Incident Reporting

A Proactive Approach A Proactive Approach

Janet MagnerJanet MagnerHealthcare ConsultantHealthcare ConsultantMagallan Risk ServicesMagallan Risk Services

Accidents re-occur because we do not use the knowledge we already have

“We are slow to learn from

Experiences of Others”

Trevor A. KetzChemical Engineer

Learning from Losses

“Modern man peers eagerly back into the twilight out of which he has come, in the hope that its faint beams will illuminate the obscurity into which he is going”

E.H. CarrHistorian

“ It is searchlights, not faint beams

that shine out of the past and show us

the pits into which we will fall if we do

not look where we are going”Trevor A. Kletz

Chemical Engineer

“Normalisation of Deviance”

Risk is relative

We increase our ability to accept risk

Complacency develops

Corrie J. Pitzer - MD SAFEmap AustraliaCorrie J. Pitzer - MD SAFEmap Australia

Eeufees Disasters – 19 in 5 yrs

The healthcare environment

HC workers suffer 600,000 – 1 million injuries from needles and sharps annually

At least 1000 HC workers estimated to contract serious infections annually from needlestick and sharps injuries

Approximately 3% of needlestick injuries result in HIV exposure

Approximately 30 needlestick injuries / 100 beds / year

Nursing Facts -American Nursing Association / EPINet 1999

“Moving towards depravity”

Pascal

What is an Incident?

An unplanned sequence of events which has An unplanned sequence of events which has caused (caused (or could have caused)or could have caused) loss. loss.

(death, injury, illness, environmental or property (death, injury, illness, environmental or property damage, or business interuption, legal liability)damage, or business interuption, legal liability)

Or could have caused = potential for loss = Near Miss

The accident / near miss relationship

There are more opportunities for learningThere are more opportunities for learning

from our own and other’s experiences from our own and other’s experiences

than we can realistically process!than we can realistically process!

What conclusions can be drawn?

The Near Miss is a free object lesson !

Organization CultureOrganization Culture Fault finding rather than Fact findingFault finding rather than Fact finding Not wanting to be found “Incompetent”Not wanting to be found “Incompetent” Time wasting - extra workTime wasting - extra work Lack of trustLack of trust Fear of reprisalsFear of reprisals

Why do we not know about them?

Formulation of a healthcare industry wide CEO Formulation of a healthcare industry wide CEO

level task forcelevel task force

Blue Cross Blue shield or Michigan FoundationBlue Cross Blue shield or Michigan Foundation

American Safety Health - System Pharmacists American Safety Health - System Pharmacists

(ASHP)(ASHP)

Near miss reporting in healthcare

Uniform Nation-wide system of mandatory Uniform Nation-wide system of mandatory reportingreporting

Voluntary reporting of medical errorsVoluntary reporting of medical errors

Protection grantedProtection granted

Implementation of process channelImplementation of process channel

Research analysis and communicationResearch analysis and communication

Key areas and position

ASHP News – 18/07/2003

“There is no reluctance to talk about it any more…….”

“5 to 8 years ago errors were something to sweep under the carpet and you don’t know you have a problem unless you look under the carpet”

“Anonymous-reporting policy led to the volunteer non-punitive-reporting policy now in place”

….brainstorm how we can improve”

“the drop boxes have increased the number of near miss reporting by 5 times”

Incriminating - legal liabilityIncriminating - legal liability

Loss of confidentialityLoss of confidentiality

Punitive, ThreateningPunitive, Threatening

DemotivatingDemotivating

Criminal implications of reporting

Trends

Report Form

Opportunity to Share

Prevent Recurrence

Evaluate causes

React positively

Process to Follow – R E P O R T

React positively

Attitude of Line ManagerAttitude of Line Manager

Team ApproachTeam Approach

Well Trained Well Trained

ObjectiveObjective

Evaluate Cause

Systematic Approach – Causal / Fault Tree Systematic Approach – Causal / Fault Tree

analysisanalysis

Analyze through to basic (underlying cause)Analyze through to basic (underlying cause)

Good questioning techniques - 5 Why’sGood questioning techniques - 5 Why’s

Prevent a recurrence

Comply with PolicyComply with Policy

Effectively appliedEffectively applied

Risk not shiftedRisk not shifted

Short and Long term solutions Short and Long term solutions

Opportunity to Share

Demonstrate ConcernDemonstrate Concern

Cost ImplicationsCost Implications

Develop a culture of learningDevelop a culture of learning

(Also stands for (Also stands for OOrganized Approach) rganized Approach)

Report Form

“The job is not complete until the paper work is done”

Easy to useReadily availableDistinctive colour

All the necessary legal requirements

Trend Analysis

Trevor A. KetzChemical Engineer

Learn from Experiences of OthersLearn from Experiences of Others

Learn from our Own ExperiencesLearn from our Own Experiences

Develop a culture of Non Blame / Fact Develop a culture of Non Blame / Fact Finding / TrustFinding / Trust

Set up a reporting system that will identify Set up a reporting system that will identify and analyze critical behaviorsand analyze critical behaviors

REMEMBER - R E P O R TREMEMBER - R E P O R T

Summary

3% of needlestick injuries result in HIV exposure!

Healthcare Waste Management Conference in Africa Today

Incident Reporting Incident Reporting

A Proactive Approach A Proactive Approach

Janet MagnerJanet MagnerHealthcare ConsultantHealthcare ConsultantMagallan Risk ServicesMagallan Risk Services