Incident reportWHO defines a patien

Incident report
WHO defines a patient safety incident as “an event or circumstance which could
have resulted, or did result, in unnecessary harm to a patient” and an event as
“something that happens to or involves a patient.”19 (p.22) WHO79 has recommended
that healthcare personnel or an organization report incidents and adverse
events in a system so as to identify hazards and risks. The incident report
system can provide information on where the system is breaking down, thus
enabling prevention of future incidents.79 Healthcare organizations and individuals
benefit from reporting incidents if, after analysing and through generalizing,
useful information is fed back to them.80, 81 According to Mahajan,
80 incident reporting should contain data input that is independent and
non-punitive; the data should give personnel the opportunity to give their
own version of the event, to reflect on the true nature of the incident; the
analysis should turn the report into a lesson and should be performed by an
expert using a standardized methodology; the feedback purpose is to learn
from mistakes and to safeguard that the system is improved, the goal being
to ensure better patient safety. It is also important that all personnel see
something positive coming out of the incident reporting.80 In the present
thesis, an incident report is defined as “A process used to document occurrences
that are not consistent with routine hospital operation or patient care”.19 (p. 120)
According to Reason,82 human error can be viewed in two ways: the person
approach and the system approach. The person approach assumes that
bad things happen to bad people and results in naming, blaming and shaming.
The system approach assumes that humans are fallible, that errors are to
be expected and errors are seen as consequences of systemic factors. A central
idea is that of system defences. In Reason’s Swiss Cheese Model, it is
presumed that a system has multiple defensive layers that prevent the occurrence
of adverse events. The defensive layers can be comprised of active
failures (e.g., forgetting to administer or administering the wrong medicine)
and latent conditions (e.g., time pressure, understaffing). When an adverse
event occurs, the important issue is how and why the defences failed.82 Reason
et al.81 also claimed that an organization that is more vulnerable to adverse
events is a system characterized by blaming individuals, denying the
existence of systemic error and the pursuit of productive and financial indicators.
81 In the 1940s, investigation of critical incidents was first used as a
technique to improve safety among military pilots.83 According to Reason,82
effective risk management depends on establishing a reporting culture, because
the same circumstances can provoke similar errors, regardless of the
people involved.82 Reason et al.81 also proposed that double-loop learning
could be used to recognize systematic causes

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Report incident
WHO defines a Patient safety incident as "an event or circumstance which could
have resulted, or did Result, in unnecessary harm to a Patient" and an event as
"Something that happens to or involves a Patient." 19 (P.22. ) has WHO79 Recommended
that Healthcare Personnel or an Organization Report incidents and adverse
events in a System so as to Identify hazards and risks. Report the incident
System Can provide information on where the System is Breaking down, thus
enabling Prevention of Future Incidents.79 Healthcare organizations and individuals
from Benefit Reporting incidents if, after Analysing and generalizing Through,
useful information is fed back to Them.80, 81. according to Mahajan,
80 incident Data Reporting should contain input that is Independent and
non-Punitive; the Personnel Data should give the opportunity to give their
own Version of the event, to Reflect on the true nature of the incident; the
Analysis should turn the Report Into a lesson and should be performed by an
Expert using a standardized methodology; Feedback is the purpose to Learn
from mistakes and to Safeguard the System that is improved, the Goal being
to ensure better Patient safety. It is also important that all Personnel See
Something positive Coming out of the incident Reporting.80 In the present
Thesis, an incident is defined as Report "A Document Process used to OCCURRENCES occurrences
that are not consistent with routine or Patient Care Hospital Operation" .19. (P. 120)
According to Reason, Human Error 82 Can be viewed in Two Ways: the person
and the approach System approach. Assumes that the person approach
Bad Bad Things happen to people and results in naming, blaming and Shaming.
Humans are fallible The System approach Assumes that, Errors that are to
be expected and Consequences of Errors are seen as systemic factors. A Central
Idea is that of System defenses. In Reason's Swiss Cheese Model, it is
presumed that a System has multiple defensive layers that Prevent the occurrence
of adverse events. Can the defensive layers be comprised of active
failures (eg, forgetting to Administer or administering the Wrong Medicine)
and latent conditions (eg, time pressure, understaffing). When an adverse
event occurs, the Issue is important How and why the defenses Failed.82 Reason
et Al.81 also claimed that an Organization that is more Vulnerable to adverse
events is characterized by a System blaming individuals, denying the
existence of systemic and Error. the pursuit of Productive and Financial indicators.
81 In the 1940s, First Investigation of Critical incidents was used as a
Technique to improve safety among Military Pilots.83 According to Reason, 82
effective risk depends on establishing a Management Reporting Culture, because
the Same circumstances. Errors Can provoke similar, regardless of the
people Involved.82 et Reason Proposed Al.81 also double-loop Learning that
could be used to recognize systematic causes.