INCIDENT REPORTING AND

ANALYSIS

Oct 16,20014
 INCIDENT REPORTING AND
ANALYSIS
INCIDENT - an unintended or unexpected event
that led to patient / staff harm including death ,
disability , injury , disease or suffering.

ERROR a slip, lapse , mistake or violation that

leads to an incident.

NEAR MISS any situation that could have

resulted in an incident , but did not due to either
chance or intervention.
 JUSH Incident Reporting and
Analysis Procedure
1. Incident handling

2. Incident reporting

3. Incident analysis

4. Taking action

5. Monitoring effectiveness of actions

 Incident handling
A ny incident has to be handled to
limit the negative consequences
of the event prior to spending any
time to report the incident.
 INCIDENT REPOTING
Incidents,errors and near
misses were reported in a
confidential reporting system.
- incident boxs
- incident reporting forms
 INCIDENT ANALYSIS
With close attention from JUSH
incident reporting officer, department
level quality improvement sub- teams
will analyze incident data related to
their departments.
A systems approach to analysis of
incidents will answer questions like:
-what went wrong?
- where it happened ?
 Taking actions
Once the causes are identified
action can then be taken to
minimize or prevent the incident
from happening again.
 Monitoring effectiveness of
actions
The incident reporting officer was
follow if the action taken has been
adequately implemented by the
appropriate department and
whether it has brought the desired
effect.
 RISK MANAGEMENT
RISK can be defined asthe
likelihood, high or low , that
somebody or something will be
harmed by an unwanted event or
incident , multiplied by the
severity of the potential harm.
 Risk management activities in
JUSH
Assessing the environment for
potential risks to patients and
other members of the hospital
community.
Taking actions to minimize any
risks identified.
 Risk assessment involved 5
steps
Step 1 Identify the
hsazards(what can go wrong? )
take into account things that have gone
wrong in the past and near miss
incidents.Walk around the work place and
talk to patients and staff.Map or describe
the activity to be assessed. It may be
necessary to involve a multidisciplinary
team.
 Step 2 Decide who might be
harmed and how
what can go wrong, who is exposed to
the hazard?
Step 3 Evaluate the risks
How bad ? How often ? Decide on the
precautions.Is it necessary to take further
action ?
 Step 4 Record the findings
and proposed actions
Based on the findings , actions should
be proposed and responsible persons
should be assigned to lead each
proposed action.
 Step 5 Review the risk
assessment and update if
needed
Risk assessment is a continuous process.
Teams need to update the risk
assessment and/or proposed actions as
they understand the risks and their
possible solutions better.