INCIDENT REPORTING

& LEARNING FROM ERROR

Patient Safety Unit
Quality in Medical Care Section
Ministry of Health Malaysia
@ Secretariat, Patient Safety Council Malaysia

In Collaboration with :
Patient Safety Module Technical Committee

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 Learning Objectives
• Understand the basic concept of incident reporting and
learning system.

• Understand the differences between error, violation and

near miss

• Understand the role of Junior Health Care Professional in

improving Patient Safety through incident reporting and
learning system

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 Patient Safety

1 in 10 patients is harmed while receiving hospital care

( Estimation in developed country ) -W.H.O

Malaysia Hospital admissions in 2013 → 3,323,024

Estimated adverse events (10%) → 332,302

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 Patient Safety

Medical error is the third leading cause of death

in the United States which accounts for 10% of
all US death
10% Makary et al., BMJ, pg. 353; May 2016

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 Examples of Patient Safety Incidents

INCORRECT SPECIMENT
MEDICATION ERROR LABELING
→ POOR HANDWRITING → WRONG PATIENT
→ INCORRECT DOSE
→ UNAWARE OF PATIENT ALLERGY

WRONG SURGERY /
PROCEDURE
TRANSFUSION ERROR → WRONG PATIENT / SITE / SIDE

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 Examples of Patient Safety Incidents
BEWARE!!
IT COULD HAPPEN TO
ANY PATIENT UNDER
YOUR CARE!

PATIENT FALL INFANT DISCHARGE TO

NOT AWARE OF FALL RISK THE WRONG PERSON
WRONG PATIENT
IDENTIFICATION
INJURY TO NEONATE POST
( SWITCHED PATIENT TAG) DELIVERY
RETAINED FOREIGN ERB PALSY
BODY SHOULDER DYSTOCIA – NOT
E.g. POST PARTUM ( TAMPOON AWARE OF RED FLAGS AND
/ GAUZE ) UNASSISTED

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 Types of Patient Safety Incidents

PATIENT SAFETY
INCIDENTS

ERROR VIOLATION NEAR MISS

NON – INTENTIONAL INTENTIONAL DEVIATION AN ERROR THAT HAS

DEVIATION FROM AN FROM AN ACCEPTED BEEN PREVENTED
ACCEPTED PROTOCOL OR PROTOCOL OR STANDARD
STANDARD OF CARE.
BEFORE IT OCCURRED
OF CARE.
“TAK SENGAJA” AGAINST THE LAW
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 Types of Patient Safety Incidents

ERROR VIOLATION NEAR MISS

ACCIDENTALLY wrote Take blood pre- and Wrong dose of medication

wrong unit on medication post-potassium correction being prescribed but
prescription but send the same sample DETECTED BEFORE IT IS
e.g : 10mg instead of 10µg INTENTIONALLY ADMINISTERED
( pre-sample ) twice and to the patient
resulting in
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over-correction
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 What Should You do
If an Incident Occur?

? WHEN AN INCIDENT OCCUR…

X √

DON’T HIDE IT REPORT IT

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 WHY SHOULD YOU REPORT IT?

DAMAGE CONTROL IMPROVE QUALITY & SAFETY

PREVENT WORSENING OF
LEARNING FROM
OF HEALTHCARE
SITUATION MISTAKES IMPROVE SYSTEM DEFECT

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HOW TO REPORT
AN INCIDENT?

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 Incident Reporting & Learning System 2.0

THE PRINCIPLES
1. Report
2. Respond
3. Share

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I.R 2.0 FORM

SECTION A:
FILLED BY H.O WHO
IS INVOLVED /
WITNESS THE
INCIDENT

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 Example of Reportable Incidents
•Medication error
•Wrong transfusion
•Wrong Surgeries/ procedures
•Patient fall
•Obstetric related incidents e.g neonatal injury during birth
•Adverse outcome of clinical procedure
•Patient suicide
•ANY INCIDENTS RELATED TO PATIENT SAFETY

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 Action to Take as a
Junior Health Care Professional
PATIENT SAFETY INCIDENT OCCUR

IMMEDIATE CORRECTIVE MEASURE/

1 DAMAGE CONTROL

AS A JUNIOR INFORM SUPERIOR

HEALTH CARE
PROFESSIONAL
2 ( e.g. MO , Specialist or other available
experienced officer )

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 Action to Take as a
Junior Health Care Professional
PATIENT SAFETY INCIDENT OCCUR

FILL IN FORM I.R 2.0 ( AS WITNESS /

3 PERSON INVOLVED )

The incident will be investigated and

AS A JUNIOR
HEALTH CARE
action will be taken to prevent further
PROFESSIONAL occurrence of the incident.

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 Overview of Incident Reporting

INCIDENT
MONITORING OF
OCCUR
ACTION PLAN

IMMEDIATE ACTION /
DAMAGE CONTROL
ACTION TAKEN & FURTHER
OCCURANCE OF
INCIDENCE PREVENTED

INCIDENT INFORM SUPERVISOR

INVESTIGATED BY FILL IN INCIDENT
INVESTIGATION TEAM REPORTING FORM
(e.g : Root Cause (SECTION A)
Analysis

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 Examples of Improvement Achieved Through
The Incident Reporting System
1 PROBLEM IMPROVEMENT

WRONG SURGERY • SAFE SURGERY SAVES

( DONE ON WRONG LIVES PROGRAM
PATIENT/ SITE / SIDE ) • SSSL CHECKLIST
SAFE SURGERY SAVES LIVES
PROGRAM
SSSL CHECKLIST

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 Examples of Improvement Achieved Through
The Incident Reporting System
2 PROBLEM IMPROVEMENT

• USAGE OF STICKER TO
BCG VACCINE
INDICATE BABIES THAT
MISTAKENLY INJECTED
HAD RECEIVED THEIR
TWICE TO BABY IN NICU
VACCINATION
USAGE OF STICKER TO INDICATE
BABIES THAT HAD RECEIVED THEIR
VACCINATION

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 Examples of Improvement Achieved Through
The Incident Reporting System
3 PROBLEM IMPROVEMENT

• USAGE OF ULTRALOW
GERIATRIC PATIENT HOSPITAL BEDS FOR
FALLING FROM NORMAL GERIATRIC PATIENT
HOSPITAL BED • PATIENT FALL
PRECAUTIONS USAGE OF ULTRALOW
HOSPITAL BEDS FOR
GERIATRIC PATIENT

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 Take Home Message

✓ We need to take action to improve and prevent similar incident

from happening again

✓ Incident reporting is not just about “paper work”, the aim is to

improve our system and as a Junior Health Care Professional, you
can play an important role in improving our system.

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 AND
REMEMBER
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DON’T HIDE IT
REPORT
25 IT!
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Acknowledgement:

Dr. Nor ‘Aishah bt Abu Bakar

Dr Fadzlinda Shaharuddin
Dr. Mohd Suffian bin Mohd Dzakwan
Dr Muhamed Faruqi Uzair Mohamed Sidek
Dr. Khairulina Haireen bt Khalid
Dr Aida Amir
Dr. Ahmad Muzammil bin Abu Bakar
Puan Wan Rahayu Wan Hasan
Pn. Sharmila Mat Zain

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