What is Incident Monitoring?

In the health care context, incident monitoring involves the voluntary reporting of events which:

• could have or did harm a patient, visitor or staff member
• involve malfunction, damage or loss of equipment or property
• could lead to a complaint or litigation.

When things do go wrong it is important to find out not only What happened?, Where? and When? but also to carefully and consistently draw out the underlying causes and contributing factors-How? and Why? the incident occurred. Incident reports can be generated by the people involved in an incident (staff, patients and visitors) or by people who witnessed or suffered from the incident. First-hand information can provide valuable insight into how and why the incident occurred so strategies can be devised to prevent similar occurrences.

Incident monitoring enables organisations to identify particular areas of concern and devise interventions. Successful implementation of incident monitoring by health units has been followed by improved individual staff morale with fewer personnel feeling completely powerless to effect change.

Explicit criteria for assessing the degree of risk can be expressed as a “risk matrix” which enables the severity of the outcome old an incident to be plotted against the likelihood of the incident recurring (see diagram below). This can be used as a tool to set priorities and identify areas that require root cause analysis of further attention.

Many of the things that can go wrong in the health care environment do so very infrequently and may only be seen in an individual health unit - even a large one-once or twice a year⁷. An individual organisation would therefore take an unacceptably long time to build up sufficient data to characterise these problems and understand the relevant causal factors. For this reason, AIMS collects and aggregates de-identified incident data into local, state, national and international databases. Such depth and breath of coverage is vital for providing the information necessary for developing system-wide strategies to better detect, manage and prevent problems.

 

 

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⁷ Runciman WB, Edmonds MJ, Pradhan M, Setting Priorities for Patient Safety. Qual Saf in Health Care 2002 (11; 224-229)