1. 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

2. 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’’.

3. 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

4. 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

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

6. 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

7. 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

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

9. 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

10. 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

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

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

13. 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

14. Some examples of incidents reported and action taken

15. 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

16. Transfusion policy for newborns

17. 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

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Reported to pharmacy and batch withdrawn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

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

20. 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

21. X-ray taken with electric matress under the baby

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

23. Problems during inter-hospital patient transport
Use of transfer checklist

25. 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

26. 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