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A review of patient safety reporting in SA. May 2021
BETTER HEALTH PROGRAMME SOUTH AFRICA
SUMMARY REPORT
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MAY 2021
A review of patient safety reporting in South Africa
INTRODUCTION
Patient safety is a fundamental element of healthcare, and inadequate patient safety is widely recognised as a public health concern, leading to unnecessary deaths and costing governments millions.
It is believed that only around 10-20% of errors globally are ever reported. However, of those, 90-95% cause no harm to patients. There is a wealth of literature that describes different factors that contribute to under- or misreporting of incidents by healthcare workers. These include weak patient safety cultures; fear of punishment; not knowing who is responsible for reporting; lack of user-friendly reporting systems; and lack of time.
Simple user-friendly reporting systems are essential to overcome the barriers and challenges to reporting patient safety incidents. The World Health Organization (WHO) has provided global guidance for a clear, standardised Patient Safety Incident Reporting System (PSIRS) in the form of the Minimum Information Model (MIM). The MIM reporting system set out three layers of reporting for each incident. These are:
• Description – what happened • Explanation – why it happened • Remedial action – what action was taken South Africa has recognised that patient safety is a crucial part of quality of care. In 2016 it was decided to develop a unified national system for reporting patient safety incidents (PSI) within the public health system using the WHO MIM-based system. A rapid assessment of MIM was undertaken by the National Department of Health (NDoH) which found that the classifications and categories, as set out by the WHO, were possibly too extensive. These were then refined for local use and implementation of the Patient Safety Incident Reporting System (PSIRS) began in 2018.
ABOUT THE REPORT
On request from the NDoH, the Better Health Programme South Africa (BHPSA) commissioned two consultants to undertake an analysis of patient safety incidents reported over a two-year period (1st April 2018 to 31st March 2020). The key objectives were to understand whether the MIM classification system is being used correctly; to identify trends of misuse; and to make suggestions for the future to support improved use of the system.
Anonymised data was extracted from PSIRS which accounted for all reported incidents from all nine provinces. A total number of 38,861 incidents were extracted and analysed. These accounted for incidents recorded at 851 public facilities including hospitals (district, regional, tertiary, central and specialised), clinics and community health centres (CHCs).
This document is a brief summary of the findings of the consultants written up as a 46-page report:
“Data analysis and review of the Patient Safety Incident Reporting Data based on the WHO Minimum Information Model.” January 2021.
SUMMARY REPORT
FEBRUARY 2021 11,177
8,000
6,000
4,000
2,000
0
6,033
4,471 7,286
6,583
39 1,852
667 151
Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northwest Northern Cape Western Cape
■ Figure 1: Incidents recorded per province
2. Review of the NSP the indicators in the NIDS are not prescribed by the (May 2020 version) WHO GMF, they are voluntary indicators. Of greater The report identifies some key constraints regarding the successful implementation of the draft NSP. Many of these constraints are due to a significant proportion of the planned activities not being 5 concern is that none of the 25 WHO-prescribed (mandatory) NCD indicators are currently defined in the NIDS. This implies that NDoH is non-compliant with the WHO GMF standard. adequate to achieve the expected outputs. The In conclusion, the national NCD surveillance system review found that 36% of the expected outputs 2 is currently rudimentary and does not support
Incident severity: 49% of all incidents resulted in a harmful, adverse effect and 51% recorded as either no harm or near misses. Classification of incident: the main classification of incident was noted as “behaviour” and accounted for 32% of all incidents. This was followed by the “other” category at 23%. Contributing factors: patient factors were regarded as the main contributing factor for incidents, followed by staff factors. Patient outcomes: 32% of incidents resulted in mild harm, with 29% recording no harm to the patient. 18% of incidents recorded death as the patient outcome. Organisational outcomes: the most common recorded organisational outcomes were an “increase in required resource allocation for the patient”. A small percentage of cases resulted in a damaged reputation, formal complaint, property damage, legal ramifications and media attention. 2818
1025 2509 2537 28 625
846 502 342 74 5003
850 1079 192
2369 2944 39 19 1312
3927 2967 6 1035
The Western Cape leads the provinces in incident reporting, followed by Gauteng, KwaZulu-Natal and Eastern Cape. It is important to note that high levels of reporting are not necessarily indicative of a less safe environment for the patient but instead could highlight a good reporting culture. A quantitative analysis of the incident reports resulted in the following findings: Increase over time: incident reporting increased over the period of study, from April 2018 to March 2020. Time of day: most incidents were reported during the morning hours and the peak time that incidents occurred was at 8am. After 3pm, there was a steady decline in incidents until 4am. Location of incident: over 80% of all incidents took place on inpatient wards. 100% 80% 286 58 5464 60% 40% 20% 0% Eastern Cape Free State Gauteng KwaZulu-Natal Limpopo Mpumalanga Northwest NorthernCape Western Cape Adverse event Near miss No harm ■ Figure 2: Degree of harm from incident, by province
BHPSA BETTER HEALTH PROGRAMME SOUTH AFRICA QUALITATIVE FINDINGS Language: data entries were entered predominantly in English but other languages were used. Reporting standard care: on occasions, poor outcomes were reported when a patient safety incident had not necessarily occurred.
Variation in detail: text descriptions varied from meticulous detail to lack of any narrative at all (7%).
Standard text descriptions: on occasions, duplicate responses were provided for different incidents which raises the risk of the entries being viewed as a “tick box” exercise, missing specific detail of the incident or learning.
Inconsistency: there were often discrepancies between text descriptions and quantitative data for the same incident (see Figure 3 below). There was also inconsistency between how the incident was categorised.
‘Other’ category: There was widespread overuse of the “other” category. For example, when categorising types of incident, 40% of all deaths were marked as “other”. 2. Review of the NSP 100% (May 2020 version) 80% 60%
40%
SUMMARY REPORTRECOMMENDATIONS
FEBRUARY 20211. Optimal use of PSIRS The report offers a number of considerations to improve the usage of the PSIRS. User-friendly interface: A number of changes could improve usability including updating the sequence of inputs to support storytelling; and design features, such as single column forms and simple navigation mechanisms. Other additions could include the functionality to attach more detailed files to reports and a spell checker. Guidance: More accessible, real-time/interactive guidance can support users of the system. ‘Tooltips’ or text labels could provide an extra layer of support, for example by providing information on what needs to be included in different sections. Refinement of categories and subcategories: a detailed list of suggestions for language/ classification changes are provided that could enhance the efficiency and usability of the system. These relate to incident type, contributing factors and outcomes. The list is available from the NDoH.
Introduce a new Severity Assessment Code
(SAC). The SAC rating used in NDoH is based on three categories that describe permanent harm, temporary harm and mild harm (SAC1, 2 and 3 respectively). However, this three-tier classification does not allow the accurate classification of “no harm” or “near miss” incidents. Introducing SAC4, to capture “no harm” or “near miss” could increase the accuracy of the system.
the indicators in the NIDS are not prescribed by the WHO GMF, they are voluntary indicators. Of greater The report identifies some key constraints regarding the successful implementation of the draft NSP. Many of these constraints are due to a significant proportion of the planned activities not being None Mild Moderate Severe Death Adverse event Near miss No harm 20% 0% ■ Figure 3: Comparing patient outcome with severity attributed to incident Findings were also made on the usability of the SA PSIRS. These included: Terminology and jargon: the language in the classification system was not always clear to the user. Sequencing: the order of the questions in the PSIRS was not always intuitive or in a natural order. concern is that none of the 25 WHO-prescribed (mandatory) NCD indicators are currently defined in the NIDS. This implies that NDoH is non-compliant with the WHO GMF standard. adequate to achieve the expected outputs. The Level of information: the system includes additional questions which are not always necessary for notification of incident. In conclusion, the national NCD surveillance system review found that 36% of the expected outputs is currently rudimentary and does not support are unlikely to be achieved due to a misalignment the collection of data for the 25 recommended
Include response, action and mitigation for
the future. A multi-incident root cause analysis is useful for investigating recurring problems and the changes needed to prevent them. While the PSIRS allows for this, it is not clear that it is routinely used. Record where and how the learning has been disseminated. Detailed documentation of learning from incidents could have benefits for all users. The lack of feedback from incident reporting has been highlighted as inhibiting the willingness of staff to report incidents. Include “time to report” and “time to close” in the dashboard. These aspects are an indication of how systems may be improving over time and therefore need to be included in reporting. 3
BHPSA BETTER HEALTH PROGRAMME SOUTH AFRICA 2. Wider support for patient safety incident reporting The report identifies several ways to strengthen the use of the PSIRS. Training and how-to guides. Tailored training may be targeted for different staff groups. Guides could include a decision-making tool to support the categorisation of an incident, and a framework for incident narrative. What does good look like? Having a benchmark with which to compare the management of incidents could be beneficial. For example, NHS England has a central capability to review, interrogate and respond to patient safety incident reports.
SUMMARY REPORT
FEBRUARY 2021
Consider incorporating patient complaints, or perhaps near-miss events, as early indicators of unsafe care.
Promote reporting responsibilities across teams. 2. Review of the NSP Multi-professional reporting across all departments is a key indicator of a robust reporting culture and should be part of the future aim. (May 2020 version)
the indicators in the NIDS are not prescribed by the WHO GMF, they are voluntary indicators. Of greater The report identifies some key constraints regarding the successful implementation of the draft NSP. Many of these constraints are due to a significant proportion of the planned activities not being concern is that none of the 25 WHO-prescribed (mandatory) NCD indicators are currently defined in the NIDS. This implies that NDoH is non-compliant with the WHO GMF standard. adequate to achieve the expected outputs. The In conclusion, the national NCD surveillance system review found that 36% of the expected outputs is currently rudimentary and does not support are unlikely to be achieved due to a misalignment the collection of data for the 25 recommended
The UK’s Better Health Programme South Africa is a health system strengthening programme supported by the British High Commission in Pretoria and delivered by Mott MacDonald. 4
