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
http://icucalculators.org.uk/resources/NPSA.zip 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.
http://www.anwicu.org/NewHTML/Incidents/Incident%20Main%20Page.htm 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.