Medical Incident Reporting and Root Cause Analysis

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Table of Contents

Utah and Minnesota Incident Reporting Mandates
A Voluntary or Mandatory Incident Reporting
Root Cause Analysis and Sentinel Events – Variant 1
Root Cause Analysis and Sentinel Events – Variant 2
Reference List

Utah and Minnesota Incident Reporting Mandates

A lot of attention has been paid to incident reporting. Health care facilities have to follow specific requirements to ensure patients’ safety. Thus, Utah and Minnesota Incident reporting mandates are quite similar and are aimed at detecting potential hazards to patients’ safety and developing plans to prevent such incidents.

In both regions, departments, where incidents occurred, must provide their reports. Thus, according to Minnesota Statutes “, each facility shall report” to the department within fifteen working days (2013 Minnesota Statutes, 2013). Likewise, according to Utah Administrative Code, health care professionals have to report about incidents though the terms are different as facilities have to report within 72 hours or “in no event later than four hours prior to conveying a formal root cause analysis” (Utah Administrative Code, 2013). Admittedly, the frontiers in reporting are frontline personnel (especially nurses and physicians). Though, the healthcare facility is responsible for providing their reports to the specific department.

It is necessary to note that the incidents which should be reported are quite similar in both regions. This can be easily explained by existing national laws and requirements imposed. Thus, all health care facilities are required to have incident reporting mandates which cover the most common incidents (Kavaler, 2012). Hence, health care facilities report on surgical, product or device, patient protection, care management, environmental, potentially criminal, and radiologic events.

Nonetheless, there are certain minor differences. For instance, according to the Utah Administrative Code, facilities have to report about suicides of patients who are in the facility or “within 72 hours of discharge” (Utah Administrative Code, 2013). At the same time, in Minnesota, facilities have to report on patient’s suicide while in the facility only (2013 Minnesota Statutes, 2013). All facilities have to report about broken microneedles during surgery according to the Utah Administrative Code. Though, in Minnesota, broken microneedles are not mentioned.

It is necessary to note that the mandates do not specify who exactly investigates reported incidents at facilities. In practice, each facility has a committee that analyses incidents (“A national survey”, 2008). The committee includes managers as well as practitioners.

Importantly, incident reporting is protected by mandates. Thus, facilities send electronic versions of their reports to the Department. At that, the confidentiality of patients is ensured by a number of acts. It is necessary to note that only members of the committee can access reports.

Facilities also provide a root cause analysis which is analyzed at the committee. Root cause analyses are potent tools that can be utilized to develop correcting measures and action plans. The root analysis reveals mistakes that led to malfunction and contains a correcting plan. This plan includes a set of specific steps to undertake to avoid similar situations in the future. Correcting plans developed on the basis of the root analysis are employed to develop training for the staff.

A Voluntary or Mandatory Incident Reporting

Patients’ safety and high quality of services provided are core goals of healthcare facilities. Therefore, voluntary as well as mandatory incident reporting is aimed at achieving the goals mentioned above. Kalra (2011) stresses that both reporting systems (if implemented effectively) are potent tools in detecting, analyzing, and preventing medical errors. It is necessary to note that both reporting systems have advantages and certain downsides.

One of the major advantages of both reporting systems is their effectiveness in developing action plans and training sessions. Proper analysis of a variety of incidents can help develop a comprehensive action plan which can result in better performance and higher quality of services provided (Healy, 2011). It is also necessary to note that both reporting systems can supplement each other. Furthermore, several employees can report on certain incidents (especially when it comes to voluntary reports). This can help obtain a more complete picture and implement an in-depth analysis of several factors and numerous details.

As far as the advantages of voluntary reporting systems are concerned, health care professionals can be encouraged to report about incidents. At some facilities, there are certain motivation strategies aimed at encouraging employees to provide reports. Remarkably, health care professionals are not afraid of negative consequences and they can provide all the necessary details on the matter. When it comes to the mandatory reporting system, one of the most important advantages is that employees have to provide specific reports on certain incidents. Therefore, this system ensures that serious incidents will be analyzed.

However, both reporting systems are also associated with some drawbacks. For instance, people are reluctant to provide comprehensive mandatory reports. Employees are concerned about possible punishment and sanctions (Healy, 2011). Hence, the data provided are not full or even distorted. This negatively affects analysis and can lead to erroneous conclusions and ineffective action plans. It is also necessary to add that mandatory reports are not numerous. A lot of incidents remain unnoticed, which leads to repeated errors.

Voluntary reports are also characterized by certain downsides. For example, only some cases are reported. Thus, when employees assume that an incident can cause negative consequences for them, they are likely to refrain from reporting about it. On the other hand, employees can report about insignificant incidents, which can lead to an abundance of reports with little valuable information. Such reports require time for analysis and there is less time to consider more relevant incidents. Moreover, the data provided can be incomplete, distorted, or insufficient. It can be difficult to develop an effective plan on the basis of such kind of analysis.

On balance, it is possible to note that mandatory and voluntary reporting systems can be effective in enhancing the quality of services provided. These reporting systems help collect data that are utilized to develop effective action plans. At the same time, there are certain downsides. Thus, employees are likely to provide incomplete or distorted data when they feel that blame can be put on them. Besides, these systems do not ensure that all incidents are considered. Therefore, it is important to use both systems at any facility. It is also necessary to improve the reporting systems to make them more efficient.

Root Cause Analysis and Sentinel Events – Variant 1

Root cause analysis is required when sentinel events occur. Sentinel events are “unexpected events” which result in death or “serious physical or psychological harm” (Kalra, 2011, p. 57). Admittedly, these events need special attention and analysis. Root cause analysis can help identify the cause of the event. In its turn, this can help avoid similar errors in the future. For instance, a team of health care professionals tried to reduce the rate of infant abduction (Kavaler, 2012). They brainstormed possible scenarios and tried to come up with ideas to address them. Clearly, this can be effective. However, analysis of a specific case can help identify stages when something went wrong. More so, it is also possible to analyze the effectiveness of measures undertaken. It can be effective to reveal errors made and define the most optimal way to solve issues.

It is possible to consider the example of an Australian hospital. Surgeons had not reported about near misses before the number of such cases increased significantly (Healy, 2011). Surgeons understood that near-misses could show potential for serious errors which could lead to patients’ death. Surgeons considered the three most recent near misses and came up with a number of important ideas. Notably, it had a positive impact as the number of near misses decreased and surgeons had the necessary plans to use in certain cases.

Root Cause Analysis and Sentinel Events – Variant 2

Sentinel events are unexpected incidents that lead to death or serious injury of patients. These events are often analyzed in terms of cause root analysis. Health care professionals analyze a variety of factors that led to negative consequences. These factors include patients’ health conditions, measures undertaken, errors made, etc. Notably, analysis of these factors can help prevent the reoccurrence of such events. However, it is also important to remember that an analysis of such events does not always result in effective action plans. Sometimes it is still unclear whether this or that preventive measure can be effective. Each patient has individual peculiarities and different clinical courses. Even though some measures can be effective with one patient, they can be hazardous with another patient. Though, reporting about sentinel events can help health care professionals be ready for numerous situations.

Reference List

2013 Minnesota Statutes. (2013). Web.

A national survey of medical error reporting laws. (2008). Yale Journal of Health Policy, Law, and Ethics, IX(I), 201-286.

Healy, J. (2011). Improving health care safety and quality: Reluctant regulators. Burlington, VT: Ashgate Publishing, Ltd.

Kalra, J. (2011). Medical errors and patient safety: Strategies to reduce and disclose medical errors and improve patient safety. New York, NY: Walter de Gruyter.

Kavaler, F. (2012). Risk management in health care institutions. Burlington, MA: Jones & Bartlett Publishers.

Utah Administrative Code. (2013). Web.

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