The ability to identify incidents ...
...is the first step in improving patient care.
If you think an incident is serious, talk
to your local manager immediately. If it is
after hours, talk to the most senior manager
available. IIMS is not a substitute for verbal
communication. |
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Step 1. Identification
Covered in this page are Direct observation
| Indirect observation | Other
ways of identifying an incident
Often, we accept incidents because we see them
as being a normal part of the day. A patient slips
while going to the toilet and is not harmed, or
develops a known complication following surgery;
or the wrong medication is given with no adverse
outcome. These events are all incidents and must
be notified.
There are two types of identification: direct
observation and indirect observation.
If you are a manager...
... it is your responsibility
to foster a culture of safety that enables
staff to identify, notify and be involved
in the investigation of incidents.
Consider Facilitated Incident Monitoring
This is about creating
an environment where incidents are easily
recognised. Allocating time for this in the
weekly department/ward meeting provides the
ideal setting for the opportunistic identification
of incidents. Further information about Facilitated
Incident Monitoring can be found in The
Clinician's Toolkit for Improving Patient
Care. |
Direct observation
You saw it happen (or almost happen), or you made
(or almost made) the error yourself. Take immediate steps
to care for the people involved and ensure that safety
issues are addressed.
Indirect observation
You heard about the incident or discovered the error later
through:
- direct notification
- death audit
- medical record audit
- surveillance
- peer review
- morbidity and mortality meetings
- NSW Coroner
- complaints
- external reviews.
Other ways of identifying an incident
- medical record reviews and clinical audit
- peer review
- morbidity and mortality meetings
- complaints, satisfaction surveys and other
methods for collecting feedback from the patient
and/or carer/family
- reviewing coroners' reports.
Other surveillance methods include the use of trigger
tools or Limited Adverse Occurrence Screening (LAOS).
For more on identification, refer to Brand
C, Elkadi S, Tropea J 2005, Measurement
for Improvement Toolkit, Clinical
Epidemiology & Health Service Unit,
Royal Melbourne Hospital, Melbourne Health.
For more on trigger tools, refer to For more
on trigger tools, see Rozich, J D, Haraden
C R and Resar R K, 2003, Adverse
drug event trigger tool: a practical harm
methodology for measuring medication related
harm, Quality and Safety in Health
Care; 12; 194-200.
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