The Risk Management Department is responsible for investigating adverse patient events that are reported either through the BICS automated incident reporting system or that are reported directly to the Department. The department is also responsible for event reporting to the Board of Registration in Medicine, the Department of Public Health and the Food and Drug Administration.
Prompt reporting of adverse events to the department allows for timely investigation, including root cause analysis if the reported event is determined to be a sentinel event, identification and assessment of risk issues, as well as advice and support to staff. The department collaborates with Quality Management and the Patient Safety Team in developing corrective measures in response to particular adverse events.
Here are some answers for what, when, how, where, why and to whom to report adverse events.
Q: What is an adverse event?
A: An unexpected, unintended occurrence that results in injury to the patient or has the potential for causing injury. An adverse event that does not reach the patient or does not cause harm to the patient may also be referred to as a “near miss” event. Near misses must be reported as well because they may provide an opportunity to identify and correct system issues to prevent future similar events.
Q: What kind of adverse events should be reported?
A: The types of adverse events that should be reported through the Incident Reporting System include: Any patient care event that is not consistent with routine delivery of patient care or routine operation of the hospital, e.g., patient fall (with or without injury), medication error (with or without injury), equipment malfunction or failure, hospital systems issues, etc.
Q: How do you report an adverse event?
A: All adverse events should be reported through the BICS Incident Reporting System by choosing the letter “Q” in Clinical Information and then providing the information as the prompts suggest. Although cumbersome, this system allows the patient’s physician and the responsible manager to investigate the adverse event . In addition to completing the incident report, it is important that adverse events be communicated to the responsible manager or supervisor if prompt follow up is required. Adverse events that result in serious injury or death or that have the potential for causing serious injury or death should be reported immediately to the Risk Management Department via phone (617) 732-6442 or pager 11775 during regular business hours. After hours, the Nurse Administrator on call should be contacted. Within the next year, the BWH plans to replace the BICS system with a web based reporting system that will allow for fast and easy reporting of adverse events.
Q: Who should report adverse events?
A: All health care providers have a responsibility to report adverse events either through the BICS incident reporting system or directly to the Risk Management Department.Q: What happens after the adverse event is reported?
A: Once a report is filed through the BICS system, it is routed to the nurse manager and to the department “process owner” for follow-up. For example, if a medication error occurs, the nurse manager and a representative from the pharmacy are notified. There are prompts in the reporting system that allow you to name other people who you think should be notified. All of the reports remain confidential. Every quarter, the information in the reports is presented in aggregate to each department chief, care improvement team, and nursing leadership.
For additional information about adverse events, incident reporting and other patient safety-related issues, please contact: Risk Manager Janet Nally Barnes, RN, JD; Director of Patient Safety Tejal Gandhi, MD; or Patient Safety Manager Erin Graydon-Baker, MS