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Systems to support improvements
Incident reporting
What is an incident?
A healthcare incident is an event …. which could have, or did, lead to unintended and/or unnecessary harm to a person, and /or a complaint, loss or damage.
Australian Council Safety and Quality in Health Care
What needs to be done to encourage people to report incidents?
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A reporting culture is needed
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People must feel free from fear of blame if they are to report errors
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“Every effort should be made to create …an open …environment in which it is safe to report”
NPSA Seven steps to patient safety
How can the information from incident reports be used?
- Provides information about the type of incidents that are occurring
- Helps identify where safer systems are needed
- Provides information about the effect of system changes
What is a ‘Near miss’? 
- An incident which did not cause harm but could have
- Should be treated as an incident and an incident report completed
- ‘Free go’
- System change can be made without any harm having occurred
- Should be treated as important learning opportunities
- Often near misses are not reported because no harm occurred
- May be seen as creating more paperwork
- Need to be seen as an important part of improving patient safety
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