Mark Quality Incident Record Made Easy

Mark quality incident record

hi i'm mark thomas senior lecturer at london south bank university and a member of the c pearl development team the royal college of chiropractors this research project is discussing 10 years of online incident reporting and learning using cpels the chiropractic patient incident reporting and learning system as are aware there's a focus on patient safety that's paramount within global health care part of that includes reporting incidents and near misses and also learning from those in in the chiropractic profession in europe we have sea pearls to be able to do this and it was developed and launched in 2009 currently accessible to all chiropractors in the uk and members of the ecu cpels is accessible via cpus.org which is a secure anonymous online incident reporting and learning platform and enables chiropractor to share and comment on safety incidents the objectives of this study were three-fold one to review the use of the database by the profession over the last 10 years to report on frequency of incident categories and patient harm and to analyze the database to identify any key areas for patient safety improvement parts one is a retrospective analysis of the database of frequency statistics looking at reporting trends including frequency of incident categories as well as level of harm and part two is a thematic analysis used to identify themes relating to any contributory factors and subsequent learning the data set itself as i mentioned over 10-year period april 2009 to march 2019 and in total that included 268 separate incidents the trend line over the last 10 years suggests there is an increase in the amount of reporting however overall reporting appears to be at extremely low rate which is expected based on the literature around barriers to incident reporting common subcategories within the system included incidents over five percent of the total database included trips and falls which is not expected this has been highlighted previously and is a well-known risk within healthcare settings adverse events were also included and they were described and split into patient experiencing post-treatment distress or pain this was by far the largest subcategory with 28.4 of all incidents patient experience negative effects during treatment an example given in this case would be a fractured rib or clavicle this accounted for 8.2 percent of incidence on the database and more significant or serious adverse events described as patient experience significant post treatment effects example on the system given is neurological problem or disc prolapse accounting for 5.2 percent there's also a large subcategory of unspecified incidents 5.2 percent and unfortunately they were incorrectly or not categorized we also managed to identify two new subcategories with over five percent of incidents these included fainting five point six percent and missing and underlying pathology eight point two percent in relation to fainting it was clear from looking through the database that this was a theme and a keyword search identified 15 incidents most occurred in examination phase two of which during blood pressure testing the majority involved patients in the 25 to 34 year old age group patient experiencing post treatment to stressful pain as mentioned this was the largest subcategory and this data could be categorized further in some cases including acupuncture incidents nine incidents involving cervical spine 21 and incidences involving pelvic girdle 21 in relation to the cervical spine 11 cases described neurological symptoms 10 describe pain spinal relative therapy was used in majority of cases 67 majority of patients were female the patient's age range appeared evenly distributed in relation to pelvic girdle post-treatment to stress or pain pain was the most common post-treatment reaction in relation to being linked with a certain modality the most common modality this was linked to a soft tissue therapy as opposed to direct therapy to the spine manipulation or mobilization and the most common type of incident recorded involved trigger point therapy to the gluteal region resulting in pain and localized bruising majority of patients were female and all patients were over the age of 45. patients experiencing negative effects during treatment remember the example given in this case was of a rib fracture or clavicle fracture and in fact 14 incidents suggested that a rib fracture was likely to have occurred 10 out of 14 of these cases were female in relation to age distribution no patients were under the age of 44. the largest group actually in middle aged patients so age 45 to 64. and several patients over 65. now this is uh interesting to reflect on this data and the question becomes are we paying enough concern to younger patients especially in relation to a known risk of fracture osteoporosis one patient aged 45-54 had known osteoporosis another patient in the same age group was diagnosed with osteoporosis by the medical practitioner following the suspected rib fracture a recent quality standard by the royal college of chiropractors now actually recommends a screening of all patients over 40 for potential osteoporosis or osteopenia 13 of the 14 cases involved a prone of p to a thoracic or side posture manipulation technique other techniques of thoracic or lumbar regions including manipulation delivered from an a to p or the patient in a supine position were only associated with soft tissue or joint injury and not suspected rib fracture patients experience post-treatment effects there were several extremely interesting cases within this group and pathologies range from quad aquinas syndrome to stroke like events the new category of missing and underlying pathology again had a number of extremely interesting cases to review including examples of abdominal aortic aneurysm spinal pathological fracture normally resulting from cancer and what was interesting is there's some crossover between the last two subcategories and it's often decided by the clinician's perspective i.e did they feel the condition was a result of the intervention or due to the pre-existing pathology which determined how they interpreted and categorized the incident but of course when discussing serious adverse events following spinal relative therapy i cannot prove the event happened because of or in spite of treatment however it was clear that clinicians felt an absent delayed or inappropriate referral for specialist review or diagnostics played a role in this category in relation to patient harm 41 of red incidents occurred and they stated that patient harm was present of these over 50 percent were described as avoidable and over 60 percent state is likely a clinician's actions or inactions were responsible for that incident now i feel these numbers are significant and shows that there's potential to reduce patient harm for adapting or changing elements of our clinical practice in relation to grading or severity of patient harm the majority as expected were in the low grade of harm over 50 percent just over 10 11.1 percent were regarded as severe harm that's worth mentioning at this stage there's currently no available definition for the free categories of harm on the cpel system meaning there's no standard approach to the classification used by chiropractors when recording incidents in terms of learning from incidents it was uh clear unfortunately the majority of cases the emphasis was based on the reporting rather than learning from the event and some aspect of learning from the incident was only documented in just over 50 percent of cases in relation to interaction 59 comments were present relating to 39 incidents however all of these comments occurred prior to october 2015. so limitations of this study analyzing this database number one is that we're not able to demonstrate any rate of occurrence it's a passive surveillance system there's no denominator i.e there's no data on the number of patient visits available there's clearly low levels of reporting so low quantity of data and the accuracy of data recorded is very limited with significant errors and emissions meaning the lack of quality of the data as mentioned we're only able to demonstrate associations rather than causation of harm and again i've mentioned severity of harm data is not valid as there's no standardization of criteria used so in conclusion there is an increase in incident reporting over the last 10 years however still appears to be significant under reporting by the profession and shared learning is not present in almost 50 percent of cases two new incident subcategories have been identified highlighting potential patient risk thank you