Patient safety incident numbers released by Health PEI
Thousands of incidents reported, more than 100 causing serious problems or death
Health PEI has released information about patient safety incidents that have happened at its 34 facilities from September 1, 2012 to November 30, 2014. The 34 facilities include hospitals and long term care.
The numbers were released to CBC News as the result of an Access to Information request.
Health PEI refers to a patient safety incident as "an event or circumstance which could have resulted, or did result in unnecessary harm to the patient."
Incidents are broken down into 21 different categories including things like falls, problems with medications, diagnostic tests, infection control and surgery/procedures. They range from level 1 severity, which is defined as a near miss, to a level 5 severity, which is death.
For example, a level 1 incident could be a spill that did not get mopped up quickly enough, but did not lead to an accident. A level 5 incident could be a medication error that caused death.
In all, there were more than 20,000 incidents over two years. Health PEI says in 75 per cent of cases there was no harm or damage and that there are millions of tests and procedures done and medications given out each year.
There were 4,831 level 3 incidents, incidents that caused minor injury or damage, and 166 level 4 incidents, involving major injury or damage over the two year period.
‘We have some work to do’
Health PEI says it does not give an exact number of deaths, because the small number could lead to a privacy breach. The health authority does say, however, the number of deaths over the two years is between 16 and 28.
“I would characterize one as too many. And we need to continually work to make sure that deaths don't happen in our care,” said Brenda Worth, chief nursing officer at Health PEI.
“I take away that we have some work to do. Any incident is something we don't want to happen. And that's why we're putting all of our efforts right now on quality and safety. And we are putting significant efforts into safety mechanisms and improving safety.”
There are 19 quality teams across Health PEI working to improve safety.
Worth said falls and medication errors are the two most common areas where incidents happen.
Making patient safety incidents public
Health PEI says it doesn't have a way to compare itself to other jurisdictions, because patient safety incidents, or adverse events, are measured differently across the country. Worth said it is looking forward to the Canadian Institute for Health Information creating some mechanism to allow comparisons.
Some other jurisdictions, including Nova Scotia, make their adverse events public. Suzanne Rhodenizer-Rose, director of quality and patient safety for Infection Prevention and Control Nova Scotia, said the public is looking for more transparency and greater accountability.
“We felt that in reporting the number of events, it would help drive quality improvement across the system,” said Rhodenizer-Rose
“We see lessons learned from events that happened, and we can make changes based on those lessons learned right across the system, rather than having them happen in silos.”
Health PEI is considering putting its incident numbers online, but the idea is still at the discussion phase.
Notes on chart
- Numbers include a range of injuries/damage from minor to death
- Health PEI does not include numbers of incidents in cases where they are less than five. These numbers reflect only fully reported numbers, and could be two to 10 higher.
- Employee incidents are those incidents involving employees