Adverse events: reporting, analysis and a just culture
- Safe practice
When something goes wrong or nearly goes wrong, the patient is cared for, the event is reported and it is analysed to fix the system, not to punish.
What it is
Reporting incidents and adverse events reveals failures in processes and lets barriers be put in place so they do not happen again. In Colombia, the Guidelines of the Patient Safety Policy ask that surveillance of adverse events be non-punitive, that hiding them be disapproved and that they be analysed with structured methods such as the London Protocol. A just culture separates human error, which is addressed by improving the system, from deliberate violation of the rules. When there is harm, the patient and family receive honest information, support and an explanation of what will be done to keep it from happening again.
What it requires
- Know what is reported, to whom, how, through which channel and by when, per the institutional system.
- Write objective facts, without judgements or blame.
- The report does not replace the clinical record note about the patient's care.
- Feedback to the person who reported: it encourages further reporting.
- Leadership that protects reporters from retaliation.
How it is applied (and why)
- Care for the patient first: assess, mitigate harm and tell the nurse in charge and the doctor; immediate safety comes before paperwork.
- Decide whether it was an incident (no harm) or an adverse event (harm) using the Guidelines' definitions: that way the report is classified correctly.
- Record the facts and the care given in the clinical record, objectively: it is part of the patient's care.
- Fill in the report in the institutional system as soon as possible: details are forgotten quickly.
- Describe what happened, when, where and what was done, without judging or blaming anyone: the aim is to find process failures.
- Take part in the analysis if asked: whoever was present knows the contributing factors.
- Support informing the patient and family per protocol: they have the right to know what happened and what will be done.
- Apply the new barriers that come out of the analysis: that is how learning reaches practice.
How a just culture responds (according to the Guidelines)
| Situation | What it is | Response |
|---|---|---|
| Failure of care | A wrong action or an unintentional omission, in planning or in execution | Support for the person, cause analysis and process redesign |
| Safety violation | A deliberate departure from a procedure, a standard or a rule | Measures according to the institution, as well as a review of the system |
| Hiding an adverse event | Not reporting or not disclosing what happened | Disapproved or sanctioned, because it blocks improvement |
In nursing practice
- Incidents without harm are the best source of learning, because they show failures before anyone is hurt.
- Safety rounds and brief team meetings keep the topic present.
- Reporting is for learning; it does not measure the true frequency of events in the institution.
- The second victim, the professional involved, also needs support.
Common mistakes
- Reporting before caring for the patient.
- Writing the report with judgements or the names of people to blame.
- Reporting only serious events and forgetting incidents.
- Waiting days to report: details are lost.
- Hiding the event from the patient or family.
Test yourself
Think of the answer, then tap the question to see it.
What is the first thing nursing must do after an adverse event?
Care for the patient: assess them, mitigate the harm and tell the nurse in charge and the doctor. The report comes afterwards.
Which method of analysing adverse events is widely used in Colombia?
The London Protocol, along with others such as root cause analysis and failure mode and effects analysis (FMEA).
How does a just culture differ from a blame culture?
A just culture addresses unintentional failures by improving the system and supporting the person, and keeps sanctions for deliberate violations and for hiding events.
Why are incidents that caused no harm also reported?
Because they show process failures before they cause harm and allow barriers to be put in place in time.
Elsewhere in DurgiPedia
Connections
Educational content for students; it does not replace your institution's protocols, supervised clinical training or a prescriber's order. Dose-calculation examples use made-up numbers: they are educational, not a clinical order.
Sources: Lineamientos para la implementación de la Política de Seguridad del Paciente (Ministerio de la Protección Social (MinSalud), Colombia, 2008); Guía técnica Buenas prácticas para la seguridad del paciente en la atención en salud, versión 1 (Ministerio de la Protección Social (MinSalud), Colombia, 2010); Paquetes instruccionales: Promoción de la cultura de seguridad del paciente (Ministerio de la Protección Social (MinSalud), Colombia, 2010).
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Representative model, for educational purposes only.