Occurence Management & Critical Incidents
Any quality management system in any industry, including health care, expects to routinely uncover events or incidents that do not conform to policies and standard operating procedures. Often, these non-conformances at DSM are generic occurrences that do not cause harm to anyone or anything. Nevertheless, it is important that staff report these non-conformances because occurrence management may help to identify potential trends and to make system-wide improvements where appropriate.
There are times, however, when occurrences are more serious and harm does occur. These occurrences are classified in one of three ways:
Critical Occurrence: This is an occurrence event where an employee, volunteer, student, or other visitor to a DSM facility – excluding patients – has been at substantial risk for injury or even harmed or there has been harm to property, reputation, and/or security.
Near Miss: This is an event that, had it gone undetected and uncorrected, could have resulted in an undesired patient outcome where their health or well-being has been compromised, including disability, death, and admission to hospital or prolonged hospital stay.
Critical Incident: This is an event where serious harm has come to a patient in the health care system that cannot be attributed to the underlying health condition or inherent risk in the health services being provided.
Any occurrence that has resulted in harm to a person is terribly regretful, which is why the Manitoba government introduced critical incident reporting legislation across the health system in 2006. DSM follows the legislated process for reporting critical incidents. The purpose of this reporting is not to lay blame on an individual, but to look at what can be done differently and what improvements need to be made in the system to avoid similar occurrences in the future.
What do I do if I think a critical incident has happened to me or a family member?
Anybody can report a critical incident, including patients, family members or health care providers. If you believe a critical incident may have occurred as a result of the diagnostic care you received, please call:
- 8 AM – 4 PM: Main reception: 204.926.8005 – ask for the Director of Quality
- After hours: DSM Administrator on-call pager – 204.935.2759
Note: If you were unhappy with the diagnostic care you received, but no critical incident occurred, DSM still wants to hear from you. Please see our Client Services section on how to report the situation.
You can also contact your contact your health care provider or your regional health authority to report a critical incident: www.gov.mb.ca/health/rha/contact.html
Critical Incidents: The Provincial Perspective
In 2006, Manitoba introduced mandatory no-blame critical incident reporting across the health system to support a culture of learning and openness. The legislation applies to regional health authorities, hospitals, personal care homes, all licensed, land and air ambulances, the Selkirk Mental Health Centre, Cancer Care Manitoba and Diagnostic Services Manitoba.
Critical incidents are not reported to lay blame on individuals. The purpose of reporting is to look at what can be done differently and what improvements can be made to the way health care providers work. In fact, it’s important for as many critical incidents to be reported as possible, so we can learn more about the health care system and look at ways to make health care safer.
Once a critical incident is reported, an investigation takes place to determine the facts of the situation and to identify possible system changes.
The critical incident legislation also requires disclosure to the patient and/or family that an incident occurred, the facts about what happened and what is being done to address it.
As part of the investigation, recommendations for improvements are made to reduce the chances of the error happening again.
This process does not replace other disciplinary investigations such as reviews by employers, complaints to professional regulatory bodies or civil law suits. Instead, investigating critical incidents complements these processes.
For more information, please consult these sources or view “Critical Incidents: Expert Articles for Further Understanding” below:
Note: All regional health authorities, including DSM, are required to share lessons learned through Patient Safety Learning Summaries (PSLS) to Manitoba Health, Healthy Living and Seniors (MHHLS). PSLS and CI reporting are centrally managed through MHHLS. For more information please contact MHHLS at www.gov.mb.ca/health/patientsafety/ci/index.html
Critical Incidents: Expert Articles for Further Understanding
As part of continuous improvement, DSM stays current with learning and best practices with respect to quality and patient safety through partnerships, literature reviews, and education. Below we have listed some articles from expert sources to help you further understand how Critical Incident Reporting is an essential component of quality and patient safety.
Building a Safer System: A National Integrated Strategy for Improving Patient Safety in Health Care, http://www.royalcollege.ca/portal/page/portal/rc/common/documents/advocacy/building_a_safer_system_e.pdf
Critical incident reporting: Why should we bother? Tewari A, Sinha A – J Anaesthesiol Clin Pharmacol
Journal of Anaesthesiology Clinical Pharmacology | April-June 2013 | Vol 29 | Issue 2
Critical incident reporting and learning
British Journal of Anaesthesia 105 (1): 69–75 (2010)
Saskatchewan Surgical Initiative
Interventions to increase clinical incident reporting in health care – The Cochrane Library – Parmelli – Wiley Online Library, http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005609.pub2/abstract
Saskatchewan Critical Incident Reporting Guideline: http://www.health.gov.sk.ca/critical-incident-guidelines