No Harm No Foul: If Nobody Gets Hurt, Is it an Incident?

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In the book HEALTH PROMOTION THROUGHOUT THE LIFE SPAN, by Carole Edelman and Carol Mandle. Mosby, Inc. Chapter 3 discusses medical errors and refers to the 1999 Institute of Medicine (IOM) research study, To Err is Human: Building a Safer Health System. I had also read an article in OUTCOMES MANAGEMENT titled An Innovative Method of Collecting Adverse Event Data and was very intrigued by both of the articles. So, I conducted my own study at the small, rural community hospital that I am employed. I had noticed that only a small percentage of medical errors were being filed as incident reports and I wanted to know WHY. I made up an Anonymous Adverse Event Survey Questionnaire. For 10 days, one was given to every nurse at the beginning of each shift and to be returned in a plain brown envelope at the end of each shift to keep it anonymous. Over the years, I had heard a lot of grumbling that “Management doesn’t do anything with the incident reports anyway” so I had included that in the 11 reasons for not filing an incident report. The results were amazing. Of the 281 surveys handed out 209 were returned (74%). Of the 209 returned, 130 (62%) reported no adverse events and 79 (38%) reported adverse events. However, of 79 that reported adverse events, only 17 (22%) filed incident reports. That leaves 62 (78%) that did not file incident reports. The most commonly reported reason 21, answered no harm sustained (34%). Nurses that did not think it was an incident 14 (23%). Seven nurses (11%) thought an incident report was not necessary because they informed the nurse involved. Six (10%) did not think that the incident report is used by management as a tool for improvement. Four, (6%) did not want to take the time to file an incident report. Four, (6%) believed it was a waste of time because nothing is done with the reports. Three (5%) answered none of the above and wrote an explanation. Two (3%) feared retaliation from the nurse involved. One (2%) did not know how to use the computer incident form. Zero (0%) feared getting too many incident reports in their file. I added the first 2 reasons together, no harm sustained and did not think it was an incident to equal (57%). That is (57%) did not think they were incidents to be reported, yet according to the returned surveys 14 were medication errors and 4 were patient falls. So, the major barrier to make our healthcare system safer continues to be the question of what constitutes an error, adverse event and incident. (The complete survey report available upon request.)

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