Incident Reporting in Paediatric Wards: A Pilot study Dr Suchita Joshi MBBS, MRCPCh (UK), PhD (UK) Assistant Professor in Paediatircs Patan Academy of Health Sciences

What is a critical incident? ‘’A critical incident need not be a dramatic event: usually it is an incident which has significance for you. It is often an event which made you stop and think, or one that raised questions for you’’.

What is a clinical incident? A clinical incident is an event or circumstance resulting from health care which could have, or did lead to unintended harm to a person, loss or damage, and/or a complaint. A ‘person’ includes a patient, health care worker or visitor

Examples of clinical incidents Medication Patient falls Intended self harm or suicidal behaviour Therapeutic equipment failure Environmental hazards Problems with blood products Documentation errors Delayed diagnosis • Hospital acquired infection Incidents when a patient expresses concern with their treatment Inappropriate treatment/s

Aims of incident reporting To improve patient care To ensure safety of the patients and the staff

Why did we start reporting incidents? To identify hazards To learn about safety Many incidents happen because of ‘process failure’ Many ‘small’ errors lead to a ‘big’ event Rarely a ‘person’ failure To Support a Blame Free Environment

Methods Incident reporting form created Information regarding when and how to fill the forms was disseminated to all the medical and nursing staff Emphasized that this is a ‘Blame Free’ process Results from the pilot study and action taken to minimize repetition of incidents was discussed in presence of medical and nursing staff

Duration of the pilot study 9 months Location NICU PICU Neonatal nurseries Paediatric wards OPD Labour ward ER

Results 1: Incident category Total incidents reported: 29 Clinical incidents:21 Medication error: 11 Missed diagnosis/ inappropriate treatment: 6 Blood product transfusion: 2 Lab error: 1 Confusion re: which group to transfuse? : 1 Equipment failure: 2 Personal accident: 3 Needle prick injury: 2 Fall : 1 Violence/ Communication error: 3 Health: 0 Others: 2 Unusual drug reaction: 1 X-ray : 1

Results 2: Person affected by the incident Patient: 25 Staff: 4 Needle prick: 2 Verbal abuse by the visitor: 1 Physical attack by the visitor: 1 Visitor: 0 Others: 0

Results 4: Person completing the form Nursing staff: 7 Medical staff: 22

Results 5: Where did the incident occur? NICU 8 PICU 4 Nurseries 5 Children’s ward 8 OPD 2 Labour ward 1 ER 1

Issues discussed Security issues Drug errors Hospital policy re: needle prick injuries Precautions to be taken before x-ray Blood transfusion policy for neonates How to ensure blood gas solutions do not run out? Lack of ICU equipment Missed diagnosis Ensuring appropriate investigations are sent before blood transfusion Documentation (hypoglycaemia) Lab error

Some examples of incidents reported and action taken

Minimizing drug error Formulary for commonly used drugs in NICU Nursing staff to re-check the drugs before giving drugs whenever a new drug cardex is written or drug dosage is changed

Transfusion policy for newborns

Donor blood collection for neonatal whole blood transfusion Previous policy: Direct collection from donor in a heparinised syringe Problem: clot formation Current policy: Use of paediatric blood collection bags provided by central blood bank

Unusual drug reaction Apnea following chloramphenicol injection (4 patients) Reported to pharmacy and batch withdrawn No further issues

Consenting for lumbar puncture Previous policy: Verbal consent Current policy: Written informed consent

Making sure that the solution in blood gas analyzer does not run out The ‘traffic light’ signal in the gas machine highlighted to the residents On-call resident to check the signal every day

X-ray taken with electric matress under the baby

Error due to lack of equipment Lack of infusion pumps leading to Fluid overload and/or hyperglycaemia Delay in starting ionotropic drugs, insulin etc

Problems during inter-hospital patient transport Use of transfer checklist

Conclusion Incident reporting is feasible in our setting too It is a good way of learning from our mistakes without intimidating a single person Medication error is the most commonly reported incident Clinical incidents occur more in intensive care settings

What next? To continue reporting the incidents Discuss the incidents reported in a regular basis Try to improve quality of care by auditing our own practice To complete the audit cycle to see if incident reporting has minimized repetition of critical incidents