The reporting and analysis of patient safety incidents and near misses (and other potential-for-harm and no-harm events) are important opportunities to recognize weaknesses in the system and to put in place safeguards to prevent similar occurrences in the future. By reviewing these events and evaluating the effectiveness of the healthcare institution’s practices and procedures, the goal is to improve the safety of care.
Hospitals and institutions become aware of patient safety incidents and near misses through various means, including:
- Direct reporting by healthcare professionals involved in the patient safety incident or near miss
- Concerns and complaints brought forward by patients and families, or by healthcare professionals
- Audits (e.g. using trigger tools)
Most healthcare institutions have policies guiding the reporting of patient safety incidents or near misses. If such is not the case, CMPA supports the development of policies and procedures regarding patient safety incident and near-miss reporting. Such policies should specify a person or committee whose duty it is to receive incident/occurrence reports (sometimes called patient safety reports). These reports should be submitted only to those specified in the policy, be they a medical or nursing leader, risk manager, patient safety officer, or an internal quality improvement committee.
Understanding harm
Unexpected changes in a patient’s clinical condition most often reflect the worsening of the disease process, disorder, or the natural condition. However, some unexpected outcomes are related to healthcare delivery itself, and are called patient safety incidents.
Most patient safety incidents result from the inherent risks of investigations and treatments. Certain recognized complications or side effects may occur and are independent of who is providing the care. However, sometimes harm results from system failures. At other times, harm results from issues in the performance of one or more healthcare providers, or it may stem from a patient’s experiences of bias and discrimination when accessing healthcare. Harm may result from combinations of all of these.
Important: Physicians providing care in a hospital/institutional setting should be familiar with policies regarding the reporting of patient safety incidents and near misses, the likely approach to analysis of these events, and to what extent, if any, information related to these analyses will be communicated to a patient or others.
In addition to reporting policies, most healthcare organizations have introduced patient safety incident and near-miss incident/occurrence reporting systems. These systems should focus on capturing only factual information, recognizing that speculations or opinions might lead to misunderstandings and inaccurate conclusions. Incident/occurrence reports may not benefit from the legislation that generally protects quality improvement information from being used in subsequent legal, regulatory or other proceedings.
The legal obligation for reporting patient safety incidents or near-misses varies across Canadian jurisdictions. Healthcare professionals will need to know which occurrences require reporting, what information must be included in a report and how these reports must be communicated. For example, in Québec, the law requires the completion of a specified declaration form for accidents (patient safety incidents) and incidents (near misses)1 in government-run institutions such as hospitals.
Important: When completing incident/occurrence reports, physicians should provide only facts and not statements of blame, speculation, opinion or other commentary as to the reasons for what happened, or any recommendations. These reports are usually not considered quality improvement information and are unlikely to be protected by legislative protection. Incident/occurrence reports should not be kept in the medical record, unless where required by law.
2
Mandatory reporting of patient safety incidents beyond the hospital/institution
Certain provinces/territories have enacted legislation that requires institutions/hospitals or regional health authorities to report to a government representative (i.e., the Minister or government agency) that a patient safety incident/critical incident3 has occurred in their facility. This is generally an institutional responsibility and individual healthcare professionals usually do not play any direct role in fulfilling these reporting obligations.
Notes
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In Québec, the Loi sur les services de santé et les services sociaux (LSSSS) defines and specifies the use of these terms. A near-miss is termed an “incident” and a patient safety incident an “accident.” In Ontario, the term “critical incident” is used, which is akin to a patient safety incident.
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For example, Québec and Ontario require a copy of “incident” or “accident” reports to be kept in the patient’s hospital record.
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In Ontario, the Hospitals Act uses the term “critical incident”, which is akin to a patient safety incident.
