Patient Safety Incident Review Information

Introduction to information you will need to classify patient safety incidents in critical care.This web site contains resources or links that will enable you to classify patient safety incidents in critical care so that you can better understand the information described in these reports. The aimof this should be to help you implement changes to improve patient care.The first stage in the process is to have an Excel spread sheet that contains the free text description
of each incident from your unit as reported by the member of staff making the report. The spread sheet should also contain the free text of any manager’s report; this is normally in a single column but in some trusts is in two columns that may be called ‘actions taken’ and ‘further actions’. There will be lots of other columns but the only others that are of any interest are the date of the incident report and, if your trust has several critical care units, the column giving the location if you want to separate them out. The file can be provided to you by your trust’s risk management department or similar department for your hospital. For all hospitals in England and Wales someone will definitely be able to provide you with this file if you are a consultant or senior nurse. They hold the files because they have to upload them to the NPSA website. Having said this most colleagues in critical care have a bit of a job to find someone who will do this for them- the risk management departments often find it difficult to produce the reports for the first time and some are reluctant to give you the information that you and your colleagues have collected- don’t give up they can do it!

You may wish to review the last calendar year’s incident reports when you start; all the reports from multiple units are reported by calendar year. The useful information from the Excel file then has to be added to the Access data base that will allow classification. The database is held as a zipped file on a different web site, the link is

The database can be down loaded onto your computer, you will need the Access program installedyou may need to ask your IT department to do this for you.

Instructions for importing the Excel files are to be found on the PowerPoint presentation ‘how to import data into the access database’.

Once you have the details of the incident reports on the database together with the managers’ report and the dates of the incidents you can start to classify the incidents. Before you start to do this you should:

1. Watch the PowerPoint presentation ‘welcome lecture‘ for a general introduction as to how
to use the database.
2. Look at the definitions in the two PDF files called classifications for database 2 and
definitions of preventability. In the Http presentations these are referred to as Excel files. It is easier to print the PDFs hence I’ve posted the PDFs; you can email me for the Excel files.
3. Look and listen to the 6 Http presentations that can be found on the web site.

4. These are quite boring to listen to but if you don’t you may well make errors that take some time to sort out. Some of the information is a little incorrect as it refers to an older version of the database but they are good enough to allow you to use the newer database. It doenot include details of preventability which are covered in one of the PDF files.A typical critical care unit will produce around 200 to 300 incidents a year and to classify these on the database will take about 10 to 15 hours to do, the more that you do the faster it gets as you will remember what is in the different drop down lists. You should do no more than a couple of hours at any one time or you will get bored and not concentrate. Save the changes and go back another time to do a bit more When you have classified all of your incidents you should then be ready to export the table that sits behind the database; this is explained in the presentation ‘moving the data table between Access and Excel’ ‘. You can now look at the frequencies of different incidents. The process is designed to compare incidents between different units and over time. To do this you will need to send me the table as explained in the presentation and I will send you back the comparative report for your unit.

To allow meaningful comparison of incidents between different units you will also need to send the

completed denominator form- instructions on how to do this are contained in the presentation how
to complete the denominator form.

There are some other presentations on the website that you should also look at.

Critical Incident Data Base

2016 Incident database

Managing loss of a line with vasopressors

Loss of a line with vasopressors - algorithm


Published papers