MUHC Incidents and Accidents

The MUHC Registry for Incidents and Accidents

Since 1994, the MUHC has used an in-house database to maintain a local registry of reported incidents and accidents. The MUHC Quality, Patient Safety and Performance Department performs regular analysis of the collected data to isolate trends, and ultimately identify and implement measures to reduce and prevent risks to patients.

The MUHC encourages its staff and physicians to report incidents and accidents as one of the many activities aimed at improving safety of care and services.

The reporting of incidents and accidents is an essential component of the Culture of Safety at the MUHC which allows for:

  • Collecting data and identifying trends (see Graph #1)
  • Learning from events
  • Planning for improvement
  • Measuring the impact of improvement

Graph 1

Source: For years 2008-2009 & 2010-2011 -  MUHC database prior to SISSS
             For the year 2010-2011 - MUHC database as per SISSS.  (*) Note -  98 events excluded are not determined


Analysis

  • The increase in the number of reported incidents & accidents is a positive sign resulting from the training of staff and physicians on incidents and accidents reporting.
  • The number of reported incidents and accidents must be examined in relation to the overall volume of activity and complexity of cases familiar to a tertiary and quaternary care centre. To do so, a reporting rate is often used.
Example of yearly volume of activity at the MUHC
Over 695,000 Ambulatory visits
Over 170,000 Emergency room visits
Over 38,000 In-patients admissions
Over 31,000 Surgeries
Over 488,000 Radiology diagnostics

Graph 2

Source: For years 2008-2009 & 2010-2011 -  MUHC database prior to SISSS
             For the year 2010-2011 - MUHC database as per SISSS.

Incidents and Accidents reported by Category

Graph 3

Source: MUHC database prior to SISSS


Graph 4

Source: MUHC database as per SISSS

Incidents and accidents reported by Severity

Graph 5        

Source: For years 2008-2009 & 2010-2011 -  MUHC database prior to SISSS
             For the year 2010-2011 - MUHC database as per SISSS.  (*) Note -  98 events excluded are not determined

 

Action:
The review of incidents and accidents reported may lead to local and/or systemic patient safety initiatives. The trending data supports the priorization of these initiatives; their recommendations/plans of actions are presented to the MUHC Quality & Risk Committee as well as to the Patient Safety Committee.

Severity of the Event as per the MSSS User Guide – Definitions and examples, for using the incident/accident declaration report (AH-223A) as used in 2009-2010. It outlines the definitions for each severity category as well as providing examples to illustrate the types of events that may occur.

CategoryScaleMSSS Definition

A

Circumstances or events that have the capacity to cause error or damage (Risk Situation).

  

B

An error occurred but did not reach anyone (near miss).

    

C

An error (including errors of omission) occurred that reached the person but did not cause consequences to the person, requiring no additional monitoring nor interventions.

    

D

An error occurred that reached the person where consequences were feared or anticipated, required monitoring to confirm that it resulted in no consequences and/or required intervention to preclude consequences to the person affected.

    

E1

An accident occurred that may have contributed to or resulted in temporary consequences to the person affected requiring non specialized first aid or interventions to control/minimize the consequences.

    

E2

An accident occurred that may have contributed to or resulted in temporary consequences to the person affected requiring intervention; supplementary specialized care or treatment without the need for prolonged hospitalization.

    

F

An accident occurred that may have contributed or resulted in temporary consequences to the person affected and required supplementary specialized care or treatment with an initial or prolonged hospitlization.

    

G

An accident occurred that may have contributed or resulted in permanent consequences to the person affected.

    

H

An accident occurred that required intervention necessary to sustain life.

    

I

An accident occurred that may have contributed to or resulted in the person’s death.

Source:  Guide for using the incident/accident declaration report – AH-223A (MSSS) as used in 2009-2010.

Severity scale amended in September 2011 modifying the incidents to include severity A & B instead of A, B & C