An Analysis of Incidents Concerning Patient Safety on the Medical unit of a Selected Hospital

The purpose of this study was to identify safety factors in patient care on the medical service of a selected hospital in order to find information which could lead to recommendations for safety measures which might improve patient safety and patient care. The descriptive-survey method of research was used. Data regarding the reported incidents were collected from the regular incident report forms, in use in the hospital. for a period of one year. Data regarding potential, unreported incidents were collected from special report forms, for a period of two months. Review of available literature in the field of patient safety provided a basis of comparison for this study, and also suggested ways of categorizing and classifying the data obtained. There were eighty-two incidents reported on the regular forms and forty-four potential incidents reported on the special forms, making a total of 126 reported and potential incidents from 2,806 admissions. A very low chi-square indicated that there was no apparent significant difference between the proportion of potential and actual incidents in the several categories. Since this was true, data from the special and regular incident report forms were grouped together for analysis and study whenever possible. The largest number of incidents, 70.5 per cent were due to falls. Medication errors accounted for 19.9 per cent? burns. 4 per cent, and other miscellaneous causes 5.5 per cent. The greatest number of falls took place in the patient\u27s rooms or wards between the hours of six p.m. to midnight. There were some factors concerning the patient himself which helped to identify the accident prone patient. This accident prone patient seemed to be a patient over sixty-five years of age with a diagnosis of malignant neoplasm, cardiovascular disease or a psychiatric condition, who was also confused mentally, or drugged with hypnotics or narcotics. In a study of the nursing care plans of the patients who had potential incidents and who were thought to be accident prone, it was found that these plans showed omissions of instructions for safety in 47,8 percent of the cases. The most common cause of medication errors was failure on the part of the nurse to follow the required checking procedure, mainly, failure to check the I-dent-a-band on the patient\u27s wrist with the name on the medication ticket. Conclusions were drawn as a result of a detailed analysis of the data. Recommendations for measures to improve patient safety and patient care were made as a result of these conclusions. These recommendations concentrated on measures for the prevention of patient falls by increased attention to details of safety on the part of the nursing personnel