A tool for the concise analysis of patient safety incidents

Julius Cuong Pham, Carolyn Hoffman, Ioana Popescu, O. Mayowa Ijagbemi, Kathryn Anne Carson

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Patient safety incidents, sometimes referred to as adverse events, incidents, or patient safety events, are too common an occurrence in health care. Most methods for incident analysis are time and labor intensive. Given the significant resource requirements of a root cause analysis, for example, there is a need for a more targeted and efficient method of analyzing a larger number of incidents. Although several concise incident analysis tools are in existence, there are no published studies regarding their usability or effectiveness. Methods: Building on previous efforts, a Concise Incident Analysis (CIA) methodology and tool were developed to facilitate analysis of no- or low-harm incidents. Staff from 11 hospitals in five countries - Australia, Canada, Hong Kong, India, and the United States - pilot tested the tool in two phases. The tool was evaluated and refined after each phase on the basis of user perceptions of usability and effectiveness. Results: From September 2013 through January 2014, 52 patient safety incidents were analyzed. A broad variety of incident types were investigated, the most frequent being patient falls (25%). Incidents came from a variety of hospital work areas, the most frequent being from the medical ward (37%). Most incidents investigated resulted in temporary harm or no harm (94%). All or most sites found the tool "understandable" (100%), "easy to use" (89%), and "effective" (89%). Some 95% of participants planned to continue to use all or some parts of the tool after the pilot. Qualitative feedback suggested that the tool allowed analysis of incidents that were not currently being analyzed because of insufficient resources. The tool was described as simple to use, easy to document, and aligned with the flow of the incident analysis. Conclusion: A concise tool for the investigation of patient safety incidents with low or no harm was well accepted across a select group of hospitals from five countries.

Original languageEnglish (US)
Pages (from-to)26-33
Number of pages8
JournalJoint Commission Journal on Quality and Patient Safety
Volume42
Issue number1
StatePublished - Jan 1 2016

ASJC Scopus subject areas

  • Leadership and Management

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