What is an Incident or Adverse Event?
Incidents or adverse events can be looked at as problems that arise in the process of care delivery, usually actions or omissions by the chiropractor or members of staff. There might be several care delivery problems involved in one incident. They have two essential features:
- Care deviated beyond safe limits of practice
- The deviation had at least a potential direct or indirect effect on the eventual adverse outcome for the patient, chiropractor, staff or general public.
Examples of care delivery problems:
- Failure to monitor, observe or act
- Incorrect (with hindsight) decision
- Not seeking help when necessary
Many factors may contribute to a single problem. Here are some examples:
- Patient factors: the patient was very distressed or unable to understand instructions; language
- Task and technology factors: poor equipment design or the absence of protocols; wrong file
- Individual factors: lack of knowledge or experience of particular staff
- Team factors: poor communication between staff and chiropractor
- Work environment factors: an unusually high workload, last patient on a Friday evening
Are Reports Secure and Anonymous?
The password-protected reporting site guarantees protection for the patient and the reporter. Their identities are never revealed. Reporters are free from fear of retaliation against themselves or punishment of others as a result of reporting.
Why Should I Report?
Detecting and accurately recording incidents and errors are fundamental steps in advancing clinical risk management by learning from experience. However, incident reporting should not solely focus on adverse outcomes.
Not all unsafe actions, systems or situations will necessarily and in every case lead to bad outcomes. The potential for an adverse outcome may exist, but for any number of reasons – e.g. timely detection or just sheer luck – this outcome may not occur at all. The reporting of safety incidents is a way of sharing experiences with your fellow professionals in a way that can have a positive impact on patient care.