Incident reports—their purpose and scope - Home Study Program

AORN Journal,  July, 2003  by Debra Dunn

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Editor's note: This is the first of a two-part series on incident reports. Part II, which is scheduled for the August 2003 issue of the AORN Journal will discuss correction processes and how to reduce errors.

Horrible headlines in the mass media about medical errors are rampant these days. Everyone has read or heard about the wrong surgery being performed on a child or the wrong side of a brain being operated on by a neurosurgeon. What about the patient who died from an overdose of chemotherapy? These stories captivate people and send chills down their spines because that patient could have been them or a family member. (1)

Patients today are savvy, educated consumers who are concerned about the potential for acquiring an infection, the level of care they receive, and the qualifications of their health care providers. They believe that most medical errors are the result of the carelessness or negligence of their health care providers, whom they believe to be overworked, worried, or stressed. (2) Most Americans, however, do not understand fully the breadth of health care issues. Health care today is a complex system comprised of numerous intricate parts that interact with multiple other parts in unexpected ways. Various levels of specialization and interdependencies exist in institutions. This places health care facilities at high risk for accidents. (1,3)

Two large studies of adverse events were conducted--one in Colorado and Utah and the other in New York. They found that 2.9% of adverse events occurred during Colorado and Utah hospitalizations and 3.7% occurred during New York hospitalizations. Death occurred 6.6% of the time in the Colorado and Utah events and 13.6% of the time in the New York events. In both studies, more than 50% of adverse events resulted from medical errors that could have been prevented. These results extrapolated to the United States imply that at least 44,000 Americans die each year as a result of medical errors, but this number may be as high as 98,000. "More people die in a given year as a result of medical errors than from motor vehicle accidents (43,458), breast cancer (42,297), or AIDS (16,516)." (1(p22))

The estimated total national cost of preventable medical errors resulting in injury, which includes lost income and US household production, disability, and associated health care costs, is $17 billion to $29 billion annually. Health care costs represent more than half of this number (ie, $8.5 billion to $14.4 billion). (2) In addition to the monetary perspective, medical errors also decrease the trust that people have in the health care system and diminish satisfaction noted by both patients and health care professionals. Physical and psychological discomfort accompany longer hospital stays or disability when errors occur. Institutions incur poor publicity, damaged reputations, and financial liability from medical errors. Health care professionals pay with loss of morale and increased frustration at their inability to provide the best care possible. In addition, employers and society as a whole pay in terms of lost worker productivity, reduced school attendance by children, and poorer health of the population. (1,4)

Accidents inevitably occur--people in all lines of work make errors. Errors can be prevented, however, by designing systems that make it difficult for people to make mistakes and easy for people to do the right thing. A positive approach to risk containment and control, including learning from past errors, reduces risk. When near misses occur, instead of being thankful nothing negative happened, nurses should question what could be learned from the event to prevent future occurrences. This proactive stance is supported by the notion that to prevent is cheaper than to cure. Understanding why errors and near misses occur helps nurses improve patient safety because they learn from previous mistakes. Identifying and correcting system errors results in decreased

* personal and facility risk liability,

* regulatory sanctions,

* negative publicity, and

* harm to patients.

Although it may be human nature to make mistakes, it also is human nature to create solutions, discover alternative methods, and meet future challenges. (1,5-7)

The nursing profession is poised to play a key role in reducing health care errors. Clinical and organizational expertise allows nurses to identify systems-related errors and help correct those errors. Simplifying and standardizing processes, developing backup systems, analyzing organizational design, and performing as a team all are measures that can be taken to improve system reliability and, therefore, ultimately prevent errors and adverse events. (3)

INCIDENT REPORT NOMENCLATURE

The term incident report is common in the health care environment. Rather than a piece of paper, this is a process in which occurrences that are inconsistent with routine facility operation or patient care are documented. Incident reports are generated for four types of medical errors: near misses, adverse events, intentional unsafe acts, and sentinel events. These events may affect any person on the premises, including patients, employees, physicians, visitors, students, or volunteers. Incident reporting serves to