Enabling good incident handling

INCIDENT HANDLING TAKES TIME, but it is worth it! Even with the best intentions in mind, a patient’s outcome does not always turn out as desired or anticipated.

Incidents can happen and cause harm to our patients, owners and clinicians. By documenting and analysing incidents we reduce the risk of reoccurrence.

SYSTEM FOR REPORTING INCIDENTS

In 2018, the digital AniCura Patient Safety Improvement System (APSIS) was launched as a tool for enabling clinics to systematically document,analyse and learn from medical
incidents.

Malin Åberg, nurse and manager of the ward department at AniCura Regiondjursjukhuset Bagarmossen in Sweden says that “we see continous improvements to patient safety as we are able to capture and reflect on things that happen in our work every day. It takes time but, it is worth it”.

SHARING THE BENEFITS

In 2020, 92% of the incidents were determined preventable. In APSIS, clinics can plan and track corrective and preventive actions. Learnings are continously shared within AniCura.

AniCura Patient Safety Improvement System

 

Degree of patient harm

41% An error did occur and did reach the patient but without causing harm

34% The incident caused temporary harm to the patient

16% An error did occur but never reached the patient (near-miss)

6% The incident resulted in the death of the patient

3% The incident caused permanent harm to the patient

Types of reported event

33% Medication related incident (excl. Anaesthesia)

33% Treatment related incident (incl. surgery)

13% Anaesthesia related incident

11% Diagnostics-related incident

5% Healthcare Associated Infection

5% Patient accident


Note: These numbers are based on data collected in the APSIS system by self-driven reporting.

 

Case: CORRECT COMMUNICATION IS KEY

THE INCIDENT

A nine-month-old cat was admitted to the emergency clinic due to vomiting. After initial IV fluids treatment the cat was sent home on oral medication with pain killers and sucralfate. The venous catheter was, however, not removed before discharge. At home, the owner gave the sucralfate intravenously and as a result the cat died.

KEY LEARNINGS

  • When a drug is sent home with a patient it is recommended to include information for which patient it is intended, what drug it is, which dose to give, which administration route to use and at what time it should be given.
  • To visualise if a patient has an IV catheter in place use colour coding of the bandage. A pre-determined colour is used if the catheter is in place and once it is removed the bandage has another colour.
  • When possible, special syringes for oral administration, that does not fit to IV catheters, should be used.