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Advocating for better clinical incident reporting

Upgrading to the National Incident Management System (NIMS) has added “significant impetus” to the quality and frequency of incident reporting, according to State Claims Agency (SCA) Director Mr Ciaran Breen. Yet there is still some way to go, as is clear in a new SCA report that describes the quality of reporting as, at times, “suboptimal”.

Speaking to the Medical Independent (MI), Mr Breen said he “wouldn’t underestimate the difficulty” in getting health facilities to report incidents in a full and timely manner.

The SCA’s National Clinical Incidents, Claims and Costs ReportLessons learned, a five year review: 2010-2014 outlines the most common clinical incidents and claims nationally from 2010 to 2014 inclusive. The report identifies high-risk areas nationally so that stakeholders can provide “targeted interventions, specific education and training and focused research”, according to the Agency.

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Mr Ciaran Breen, Director, SCA

Mr Breen said it is critical that this data is used within healthcare to promote a safer environment.

“All of this is aimed ultimately at providing a safer and better environment for our patients and indeed for our doctors, because the lesser the number of incidents and the greater the quality of care, everybody gains,” he told MI.

Increase

The clinical incident rate increased nationally over the five-year period of the report, from 883 per 100,000 population in 2010 to 1,014 per 100,000 population in 2014 (an average of approximately 41,000 clinical incidents per year, comprising no-harm incidents, near-misses and incidents causing harm). The rise may be due to “increased reporting of clinical incidents, changes in clinical care, or a combination of both”, notes the SCA.

Medicine, maternity, surgery, disability and older persons’ services were the most common services in acute and community healthcare facilities that reported clinical incidents to the SCA.

The most common category of clinical incident across these five service areas was ‘Other’, followed by ‘Delay/Failure to Treat — Adverse Outcome’; ‘Failure/Faulty Medical Device/Equipment’; ‘Incorrect Dosage’; ‘Missed Medication’;  ‘Serious Soft Tissue Damage’; ‘Clinical Records Missing/Misplaced’; ‘Medication on admission/transfer/discharge incorrect or not reconciled’; ‘Post-partum Haemorrhage’; and ‘Perineal Tear (third and fourth degree,  including breakdown of perineum)’.

The report is unequivocal that the quality of clinical incident reporting has at times been “suboptimal” and “must be improved”.

Mr Breen told MI there had been “very considerable engagement” with the HSE and the group representing voluntary hospitals regarding the benefits of incident reporting, risk analysis and risk abatement measures.

Categories

In tandem with the upgrade to NIMS from the old STARWeb system, the Agency has been working to provide better access and reporting formats, as well as wider ‘pick lists’.  Mr Breen outlined that there have been continued efforts to reduce the ‘Other’ category; it is declining but nevertheless it still tops the list of clinical incident categories.

“As we have developed and progressed the system through NIMS, we have become much more specific in relation to guiding [people] away from that kind of response — of putting things into ‘Other’. So we have grossly expanded ‘pick lists’ for hospitals and the idea is that over a period of time — and we are and have significantly reduced that category —that we will reduce that category even further because nobody wants to see a large ‘Other’ category, we would prefer to see that as a much more diminished category… ”

Do time pressures also mitigate against good clinical incident reporting?

Mr Breen responded that there are issues of resourcing, while the quality of reporting systems varies. 

“What we are aiming for is to use the very good reporters — and we do this constantly with institutions, we show them where they are relative to other institutions who are reporting, so we compare ‘like with like’, and if someone is not as good at reporting, we are working with them to show them where they are falling behind their peer hospital, for example, or peer health enterprise, so there is very significant work being done on this.”

Meanwhile, on prevention of clinical incidents, the SCA report outlines a number of “opportunities for improvement and suggestions”. On the issue of prevention of delay or failure to treat — leading to an adverse outcome — the Agency notes that reduction in waiting lists “has resource implications and includes consideration of options such as the provision of direct access for GPs to certain investigations, eg, echocardiogram, computerised tomography (CT) scans and/or consideration given to a seven-day week for elective lists for diagnostics”. It also encourages introduction of an Electronic Healthcare Record and implementation of the National Clinical Effectiveness Committee (NCEC) Clinical Handover (Communication) and Early Warning System guidelines nationally.

On medication incidents, the SCA advocates implementation of clinical pharmacy services in all hospitals and introduction of a national drug Kardex, among other measures.

In regards to medical devices and equipment, the SCA says consideration should be given to hiring/leasing equipment, which may also be more economical than purchasing. “Central procurement should be employed where possible, facilitating trade discount and standardisation of medical devices and equipment nationally,” it outlines.

Asked whether its recommendations have been communicated to the HSE/Department of Health directly, Dr Dubhfeasa Slattery, SCA Head of Clinical Risk, firstly noted that these are detailed in the published report. “We do meet with the HSE national directorate on a regular basis, eight times a year, and four of those are dedicated just to clinical risk; we have a clinical risk forum meeting and we highlight clinical risks nationally… we have a sharing of information with a bi-directional flow. So we in the State Claims Agency want to get this information out to front line workers and all stakeholders as soon as possible. We weren’t delaying in sharing this information; we did share some of this information, for instance regarding equipment and consideration regarding hiring equipment rather than replacing and purchasing them every seven years, so we do share our suggestions with the HSE when we meet with them and we do meet on a regular basis and we have a very strong relationship with them.”

On the recommendation regarding equipment, Dr Slattery said the HSE was “interested” and “listened” and it is a matter for the Executive in terms of how it proceeds.  

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Dr Dubhfeasa Slattery, Head of Clinical Risk, SCA

In relation to future information initiatives around clinical risk, Dr Slattery outlined that the Agency’s initial focus has been on producing detailed analysis reports — one on maternity/gynaecology services and this recent study relating to care across services nationally, therein providing risk management suggestions.

“I think now that that has been done, our plan is that we would produce more rapid reports, so for instance we are working at the moment on a one-pager on medication incidents — a little similar to what they do in the UK, so that if an incident arises, you get that information out there quickly to people nationally and can provide guidance on how to prevent its recurrence, and NIMS facilitates these quicker turnarounds… ”

According to Dr Slattery, the Agency is engaged with hospitals on trends emerging through NIMS, with an SCA clinical risk advisor assigned to each Hospital Group. These advisors are in regular contact with risk managers in hospitals, she outlined. 

“Additionally, we do hospital site visits, both elective and triggered, and we analyse all the data over a year, right down to the minor or negligible, that is, ‘no-harm incidents’. We are constantly looking for a trend in our near-miss or ‘incident no-harm’ [data] to highlight to the hospitals, so that is being done actively.”

Another component is training delivered to hospitals so that they can run their own reports via NIMS, in addition to the SCA highlighting issues.

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