Stephen Gadd
October 25th, 2017

Share

But will they report it if it all goes pear-shaped? (photo: Calleamanecer)

An ‘unintentional incident’ is defined as being something that causes harm – or the risk of harm – to a patient. According to the law, doctors and nurses are obliged to report all such incidents, but recent research points to this often being ignored.

In 2016, there were 42,797 ‘unintentional incidents’ reported in Danish hospitals, but the real figure is probably much higher, reports Videnskab.dk.

An incident is classified as ‘unintentional’ because the people involved didn’t intend to cause harm – quite the opposite, in fact. These can arise when a safety system is faulty or lacking, if there are technical problems with equipment, through misunderstandings, loss of data etc.

Since 2013, the number of reports of ‘unintentional incidents’ from hospitals in Denmark has fallen, according to figures from the Danish database on patient safety.

The need to learn from mistakes
“It is only a fraction of ‘unintentional incidents’ that get reported, explained Jakob Kjellberg, a professor at the Danish centre of applied social science, VIVE, to Videnskab.dk.

“The problem is not that mistakes happen, because it is impossible to avoid this in a health system. The problem is that the mistakes are not reported so people can learn from them.”

A recent study carried out by researchers from Aarhus University Hospital uncovered two deaths and eight life-threatening incidents in connection with the dispensing of medicine at the hospital. All of these would fit under the heading of ‘serious unintentional incidents’, but none were reported.

“Under-reporting is taking place for all categories of ‘unintentional incidents’, noted Kurt Rasmussen, an associate professor at the institute of clinical medicine at Aarhus University, told Videnskab.dk.

“It can be anything from fairly trivial things such as when the requisition order for a blood test disappears that does not have any real impact on the patient, to the most serious incidents that have cost a patient his life.”

Not just a new phenomenon
The problem is not new. Back in 2013, Rasmussen and his colleagues estimated that only 5 percent of all cases of ‘unintentional incidents’ were reported during the period that he was then studying. One of the reasons could be that hospital personnel are just too busy.

Another Aarhus University researcher, Marianne Lisby, agrees.

“If you are under maximum pressure in an emergency department where you are often dealing with matters of life or death, you are constantly having to apportion your time,” she said.

“In a given situation, should you use your time documenting a relatively trivial thing when there is a patient whose life may be hanging by a thread? No, of course not. In that way, the reporting is put off and it might end up being forgotten.”

Maybe the system is just getting better
Under-reported or not, the number of reported incidents is undeniably falling – from 51,039 in 2013 to 42,797 in 2016.

“We can’t tell whether this is a random variation or whether there has been a real drop in the number of incidents,” Lena Graversen from the organisation for patient safety told Videnskab.dk.

“The negative connotation is that there is a downturn in the use of the reporting system. More positively, we are seeing a maturing of patient safety culture in the health system.”