Incident Review

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July, 2017. “Incident review” is a familiar term to those working in organized health care settings, particularly in inpatient psychiatric settings. The word “incident” could mean many things of course, but in clinical settings it is generally understood to refer to unfortunate adverse events that occur in the course of treatment, such as violent behavior driven by a patient’s illness, or treatment errors such as the administration of the wrong medication to a patient. The seriousness of such incidents is generally measured by whether or not the incident resulted in harm or injury to the patient or to others. Quality-of-care organizations such as the Joint Commission classify the most serious incidents as “sentinel events,” and careful “root cause analysis” of such an event is standard procedure.
During my own career, I have worked in a busy emergency room and in several psychiatric hospitals, including serving for several years as director of an acute inpatient unit, and I have participated in many incident reviews. These ranged from harmless but concerning incorrect medication doses that were ordered but not administered, all the way to devastating suicides, some following patient elopements, some in the hospital itself. During the “quiet” times of treatment as usual, it is easy enough to experience the necessary steady-state practice drills for the next unannounced survey as unwelcome interruptions to the busy day-to-day work of patient care. However, when the next sentinel event occurs, I guarantee that routine standards of good practice and careful attention to required documentation will serve you well. Believe me, I have been there when that was not the case, to the dismay of all. And I have been there when all was pretty much shipshape, to the relief of all. Even so, an adverse event may still have occurred, and a careful review of opportunities for improvement is critical. In our work, incidents happen and will continue to happen, some trivial and some tragic. However, being prepared is the wise place to be.
In this issue of the journal, Russ and colleagues describe in detail an admirable model for the structure and functioning of an Incident Review Committee. They present a helpful sample of an incident review template, along with an illustrative case vignette. Key components of the model include a fixed committee membership including senior leadership, required training of all committee members, assignment of multiple case investigators in addition to the standing committee members, and reliance on a selected single investigator to complete the review process. A plan of correction in “real time” is then essential.
Also in this issue, Sanghani and colleagues review the characteristics of patients involved in physical assault in an acute inpatient setting. Although not the primary focus of this review, the advantages of an effective Incident Review Committee are underscored here, as incidents involving physical assault are inevitably high on the list for quality control and review. Interestingly, this review suggests that a history of substance abuse is one important risk factor for violent behavioral dyscontrol, but a diagnosis of schizophrenia spectrum disorder is not.
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