Patient Safety Learning

The MUHC approaches improving the quality and safe delivery of healthcare by identifying situations that may put patients at risk and acting to prevent or control those risks.

For example, the MUHC has been tracking incidents and accidents since 1994  – long before the Quebec National Assembly introduced Bill 113 in 2002, which one of these initiatives was for institutions in the province of Quebec to establish a monitoring system to identify and track incidents and accidents. 

The MUHC has embraced the introduction of the Quebec national registry of incidents and accidents, announced by the Ministry of Health and Social Services in April 2011. This register is a means to track and analyze data trends from organizations across the entire province.

Reporting Incidents and Accidents

Despite an organization’s best efforts, adverse events sometimes do occur.  The MUHC makes it a priority to learn from these events. 

The MUHC Incidents and Accidents Reporting Policy requires that all incidents and accidents involving patients or visitors be reported to the MUHC Department of Quality, Patient Safety and Performance  Once reported, they are analyzed and used to determine what measures can be put in place to prevent them from happening again.

The Quebec National Registry for Incidents and Accidents

In December 2002, the Quebec National Assembly unanimously adopted legislation on patient safety, Bill 113, later to become an amendment to the Act Respecting Health Services and Social Services R.SQ, c. S-4.2, section 8 (HSSSA).  As a result of this legislation, the province became the first in Canada to require healthcare institutions to identify, track and ensure that measures are taken to prevent such incidents and accidents from recurring.

On April 27, 2011 the Quebec Ministry of Health and Social Services announced the launch of the Quebec National Register of Incidents and Accidents.  The Système d’information sur la sécurité des soins et des services (SISSS) will facilitate the clear and standardized reporting of incidents and accidents by all healthcare institutions across the province. The analysis of the information provided by these institutions for input in the SISSS will enable hospitals to benefit from the experiences of other organizations, in order to identify and implement corrective measures and policies to prevent similar events from happening in their own institution.

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

Incidents and accidents
Source: MUHC database as per SISSS.

 
 * Exclusion - blood glucose monitoring device event, recall of 1337 patients over a 10 yr period in June 2012.
* Exclusion - blood glucose monitoring device event, recall of 1337 patients over a 10 yr period in June 2012.

Source: MUHC database as per SISSS.

Analysis:

  • 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 volume of activity at the MUHC (2012 - 2013)
Over 735,000 Ambulatory visits
Over 173,000 Emergency room visits
Over 39,000 In-patients admissions
Over 33,000 Surgeries
Over 515,000 Radiology diagnostics

 

Graph 2


Source: MUHC database as per SISSS.

Graph 3


Source: MUHC database as per SISSS.

 

Graph 4


Source: MUHC database as per SISSS

 

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

 

MUHC Policy on Disclosure of Accidents to Patients 

The MUHC is a leader in this respect, implementing a disclosure policy in 2001, a full year prior to the legislated amendements to the HSSA.

MUHC health care providers are recognized for their dedication, training and professionalism and for seeking the best possible clinical outcomes for their patients. 

Despite our best efforts, adverse events sometimes do occur and patients’ outcomes may not be what was originally desired or anticipated.  

 


Click here
to view the MUHC Policy on Disclosure in its entirety.

The MUHC Disclosure Policy reflects the organization’s dedication to determine the cause of the accident, provide the patient involved with the necessary support, and ultimately, to develop and implement improvement strategies for better health care moving forward. The MUHC is a leader in this respect, implementing a disclosure policy in 2001, a full year prior to the legislated amendements to the HSSA.  

 

 


Definitions

Incident:
An action or situation that does not have consequences for the state of health or welfare of a user, a personnel member, professional involved or a third person, but the outcome of which is unusual and could have had consequences under different circumstances. 1 (Source: An Act Respecting Health Services and Social Services R.SQ, c. S-4.2 [“HSSSA”], section 183.2)

In Quebec, there is a distinction between incidents and accidents. In Quebec, accidents could have consequences, whereas incidents do not. In the rest of Canada, incidents include all incidents and accidents, with or without consequences.

 

Accident:
An action or situation where a risk event occurs which has or could have consequences for the state of health or welfare of the user, a personnel member, professional involved or a third person. 2 (Source: An Act Respecting Health Services and Social Services R.SQ, c. S-4.2 [“HSSSA”], section 8)

 

In Quebec, there is a distinction between incidents and accidents. In Quebec, accidents could have consequences, whereas incidents do not. In the rest of Canada, incidents include all incidents and accidents, with or without consequences.