Incident Reporting

An Incident is defined as any event that has resulted in, or could have under different circumstances resulted in unintended and/or unnecessary harm or death not related to the natural course of the patient’s illness or underlying condition. Clinical Incidents are defined as Adverse Events or Near Misses.

A formal report must be filed for ALL adverse events and near misses.

The CDHB promotes a no-blame culture.

The reporting of incidents (near misses and adverse events) is to:

• help determine why an event has occurred,
• look at all the underlying factors that have caused an incident, e.g., environment, equipment design, procedures, culture, training, organisational factors, human error etc, and
• enable steps to be taken to reduce the risk of a recurrence and to look for any trends that may be occurring over time from seemingly one-off incidents.

The overall aim of this is to improve on quality systems and procedures which will improve on patient outcomes.

Formal reporting of incidents is done electronically, via Safety1st. Access Safety1st via the following link: CDHB Clinical Incident Management procedure.

Protocol for Investigation of Adverse Reaction to Intravenous Infusion or Medicines

1. Do not throw anything away.
2. Collect all needles, drip tubing, bottles, and contents, etc. and place them in a plastic bag.
3. Label with the date and time, patient name, and list of contents.
4. Call the Microbiologist, Infectious Diseases Physician, or other relevant specialist for advice on the procedure to be followed.
5. Complete a Quality Improvement Event Reporting form.

See Blood and Blood Components Transfusion in Hospital HealthPathways for specific precautions and complications relating to blood transfusion.

Topic Code: 10807