Juho Olavi Jämsä1, Sari Hannele Palojoki2, Lasse Lehtonen3, Anna-Maija Tapper4. 1. Finnair, Finland. 2. Helsinki and Uusimaa University Hospital District, Finland. 3. Helsinki and Uusimaa University Hospital District (Finland); University of Helsinki, Helsinki, Finland. 4. Hyvinkää Hospital at Helsinki and Uusimaa University Hospital District (Hyvinkää, Finland); University of Helsinki, Helsinki, Finland.
Abstract
OBJECTIVES: To determine if and in what ways serious patient safety incidents differ from nonserious patient safety incidents. METHODS: Statistical analysis was performed on patient safety incident reports that were reported in 2015 in Finland's largest hospital district (Helsinki and Uusimaa, HUS). Reports were divided into two groups: nonserious incidents and serious incidents. Differences between groups were studied from several types of categorically divided information. RESULTS: Of the total number of reports (15,863), 1% were serious incidents (175). Serious and nonserious incidents differed significantly from each other. Serious incidents concerning laboratory, imaging, or medical equipment were more common. On the other hand, incidents concerning medication, infusion, and blood transfusion were less frequent. In serious incidents, the proportion of doctors reporting was greater, and contributing factors were better recognized, the most common being working of procedures. CONCLUSIONS: In the future, special attention should be given to the particular aspects of serious patient safety incidents, such as safe use of medical equipment, training, and handling of procedures. Root cause analysis is an effective way to handle serious incidents and enables the prevention of their reoccurrence. However, a systematic follow-up of the root cause analysis should be developed.
OBJECTIVES: To determine if and in what ways serious patient safety incidents differ from nonserious patient safety incidents. METHODS: Statistical analysis was performed on patient safety incident reports that were reported in 2015 in Finland's largest hospital district (Helsinki and Uusimaa, HUS). Reports were divided into two groups: nonserious incidents and serious incidents. Differences between groups were studied from several types of categorically divided information. RESULTS: Of the total number of reports (15,863), 1% were serious incidents (175). Serious and nonserious incidents differed significantly from each other. Serious incidents concerning laboratory, imaging, or medical equipment were more common. On the other hand, incidents concerning medication, infusion, and blood transfusion were less frequent. In serious incidents, the proportion of doctors reporting was greater, and contributing factors were better recognized, the most common being working of procedures. CONCLUSIONS: In the future, special attention should be given to the particular aspects of serious patient safety incidents, such as safe use of medical equipment, training, and handling of procedures. Root cause analysis is an effective way to handle serious incidents and enables the prevention of their reoccurrence. However, a systematic follow-up of the root cause analysis should be developed.