10 Questions from the Resident and Fellow Affairs Committee
Adrienne Green, MD, Professor of Medicine and Associate Chief Medical Officer at UCSF Medical Center answers resident and clinical fellow questions about Incident Reporting at UCSF Medical Center
- What is an Incident Report?
Incident reports are an important tool used by the medical center to identify adverse events and near misses so that we can improve systems to support patient safety.
- How do I file an Incident Report and what should be included?
The incident reporting system can be accessed from the “CareLinks” page, the link is in the second column labeled “UCSF Pages.” You will need to complete some basic demographic information, answer some questions about the event and then describe the event in free text. It is most helpful to be brief but include enough detail to facilitate the next steps in the investigation of the event. It is important to be objective. The IR system is not a good place to speculate, assign blame or vent about an event. Event details should include: what happened, who was involved and the outcome of the patient if that is known.
- What type of thing should I be reporting? What are the goals of an Incident Report system?
We encourage reporting of both serious events or errors and near misses. Reporting of serious or sentinel events, such as a retained sponge or death from a medication error, allows for rapid review with a root cause analysis and timely reporting to the state. Reporting of near misses allows us to perform a review and implement system improvements so that we can avoid errors in the future. An example of a near miss is a medication error that is caught before reaching the patient.
- What happens when I send in an incident Report?
Incident reports are categorized into 32 categories. Each category has a category manager. When an IR is filed it is automatically routed to the category manager, the nurse manager or supervisor of the area where the event took place and to the service chief and/or quality improvement representative for the involved service. For example, if a Medicine patient on 14L falls, the IR will be routed to the 14L nurse manager, the Medicine service chief and the category manager for Falls. They would investigate and review the circumstances of the fall as well as the patient outcome. If needed, improvement activities and follow up plans would be initiated. This would be documented in the IR system before “closing” the IR. Serious incidents, a fall with injury for example, are quickly escalated through the IR system to medical center and medical staff leadership for review and consideration of a root cause analysis.
- How many Incident Reports are submitted at UCSF?
10,000 incident reports are filed each year. The 4 categories with the most IRs are Medication Related Events, Skin Issues (for hospital acquired pressure ulcers), IVs Tubes and Drains (largely for IV infiltrates), and Falls.
- Is my name used if I file an incident report? What happens if someone files an incident report about me?
Yes, when you complete an incident report you will be asked to include your name. This is helpful for further investigation of the event beyond what is written in the IR. Some institutions have anonymous reporting of IRs but UCSF does not.
The most frequent IRs about residents and fellows involve unprofessional behavior, poor communication, slow response time to pages and slow response to requests for orders. If an IR is filed about you, it will be sent to your program director and/or service chief for review. He or she will contact you to hear about the event from your perspective.
- Is an Incident Report charted in the patient’s medical record? Does it go in anyone’s personnel file?
The incident reporting system is independent of the electronic health record. It is always best to consult Risk Management before documenting possible errors in a patient’s record.
Incident reports may not be copied and placed in an employee’s personnel file. In fact, they may not be copied for any purpose. An IR is a confidential and privileged communication and must be appropriately handled to protect that privilege.
- What is a Root Cause Analysis, how is it organized, and who does this?
A root cause analysis is a multidisciplinary, structured, retrospective review of an event. At UCSF we perform RCAs on serious, sentinel events as well as near misses. The UCSF Patient Safety Committee has oversight over the RCA itself and is accountable for assuring that improvement actions identified at the RCA are implemented, sustained and disseminated. Some examples of recent RCAs and the changes that were put in place have been nicely described in the GME Patient Safety Bulletins that have recently been distributed.
- Will I hear what happened to the situation about which I submitted an Incident Report?
One of the pitfalls of our current system is that we do not do a great job of closing the loop with each person who has filed an IR. In general, the more serious the error, the more likely it is that you will be a part of the review process and thus hear about the outcomes. If you have filed an IR but haven’t received feedback, it would be appropriate to ask your service chief for follow up.
- How can I learn about what comes out of the UCSF Incident Report and Root Cause Analysis system?
The Patient Safety Committee and the Office of GME are partnering to develop Patient Safety Bulletins highlighting key events, what we have learned about the root causes and what we have done to improve our systems. We also conduct a Patient Safety Grand Rounds each year in March. In July 2013 GME Grand Rounds will focus on the IR system and Root Cause Analysis.