Quality Measures: Adverse Incidents
Why this measure is important:
Adverse incidents are any event which should not have happened which poses a risk or has caused actual harm to a patient. It is vital that we record all such incidents in order to learn lessons from them to prevent future such events.
Ideally, we would want to see a reduction in the rate of adverse incidents over time.
How we measure:
We have a strict adverse incident reporting system which should catch all such incidents in any of our clinics. There is a central record of these and the figures on the graph are from those records.
What we are doing to improve:
As can be seen from the trend there was a significant increase in adverse incidents reported this year. This is disappointing but almost certainly reflects a lower threshold for what is classified as an adverse incident rather than a true increase. The actual numbers remain small and the severity of the vast majority of the incidents has been low. Comparison with threshold rates published in the Multi Society consensus quality improvement guidelines show our rates remain far lower than average.
We investigate all such incidents and undertake a root cause analysis on serious events in order to learn lessons and try to avoid repeats. The results of the investigations are shared with all staff in all our clinics.