Dear Colleagues,

I was recently talking to a respected and experienced member of our medical staff who expressed concern about treatment received by a patient that resulted in a "near miss" incident occurring. As a result of a problem in the investigation of the patient's symptoms the patient might have come to real harm. Fortunately one of our staff recognized the problem, made the correct diagnosis and started life saving therapy. The doctor speaking to me wondered how we could prevent this risk from happening again.

I suggested that he should fill out an electronic incident form and classify the incident as "near miss potentially severe" His response was simple- "I am too busy to fill out a form which everyone will ignore anyway." I realized at that moment that this excellent doctor did not understand the importance that UHN places on investigating critical and severe incidents (and near misses). And that is my fault- if one of our doctors does not understand the important role that incident reporting plays in our Patient Safety programs- then I need to communicate more about this issue.

When you fill in an incident report from the on-line clinical tools (as happens more than 5000 times a year) the report is reviewed by our Clinical Risk Management team. All critical and severe reports are followed very carefully to support the clinical manager in figuring out why the incident occurred and what steps need to be taken to protect patients. Once the clinical and management team has completed their review, the entire incident and investigation is discussed by the Quality of Care Committee which I chair. This group meets monthly for two hours. Our four Clinical Vice-Presidents, our VPMA and Patient Safety Officer (Emily Musing) join me on the Committee along with Sharon Rogers and experts from a variety of areas in the hospital.

Critical and severe incident investigations that determine how we can avoid repeated risks to our patients are conducted under the protection of the Quality of Care Information Protection Act. This provincial legislation provides legal protection to the professionals who have been involved in the patient's care. The protection of the act is important in generating honest discussion of our performance without fear of legal consequences. We do ensure however that we disclose and explain every time a patient experiences an unexpected outcome in the hospital- and we encourage everyone to apologize to patients if an error has occurred.

The Quality of Care Committee or one of its delegated committees reviews every severe and critical incident reported at this hospital. We ensure that the investigation has been thorough and that we are minimizing the chance of a repeated similar incident both in the area of the hospital where the incident occurred and in other areas of the hospital as well. If we do make changes to our usual protocols we ensure that the patient and family know that we are making changes based on the investigation of the incident.

I am happy to report that my colleague has now completed the electronic incident report on the event which concerned him. After the investigation is completed we will review the incident at Quality of Care and try and ensure that it does not happen again anywhere in the hospital. We take incident reporting and investigation very seriously at UHN- it is a fundamental element of our Patient Safety program and I want everyone to understand that we protect patients when we report incidents.

Finally I am very happy that this was a near miss incident- our excellent clinicians caught our error before harm befell the patient. These are the best incidents to investigate- when we can protect future patients without harm coming to any patient today.

Thanks for your vigilance in keeping UHN the safest hospital in Canada.

Bob

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