Development of Incidence and Adverse Event Management Model Under 9 standards for the Safety of Patients and Public Health Personnel

Abstract

This research and development aimed to study situation, develop a model and evaluate the effectiveness of managing incident and adverse events under 9 standards for the safety of patients and public health personnel. This study consisted of 3 steps: Step 1: Studying the situation of problems using qualitative research to investigate the incidence data from health care facility risk management information system during fiscal year 2018-2020 and document analysis; Step 2: Developing the incident and adverse event management model under 9 key standards necessary for safety by using the P-D-C-A principle verified by experts and evaluated with the highest suitable and consistent level (M=4.71, SD=0.26); and Step 3: Evaluating the effectiveness of a developed model employing quasi-experimental research, one group pre-post design, to implement with 30 personnel in Naradhiwasrajanagarindra hospital. Descriptive statistics, frequency and percentage, were used to analyze the data. The results revealed that:

1. The situations of incidence and adverse event management were recorded in notebook by the hospital personnel and reporting the information during the shift works, not immediately reported in the Healthcare Risk Management Information System. The incidents of E-F levels were not reviewed, while the G-H-I levels were reviewed. The results of the reviews were not included in the incidence risk list from 2018 to 2020. Medication error and drug adverse events were the most common, followed by the major infections of hospitals in Ventilator-Associated Pneumonia (VAP).

2. The incident and adverse event management 4R Model included: 1) Report: reporting the incident and adverse events within 24 hours: 2) Re-Check: verifying the incidence and adverse event data in the health care facility risk management information system: (1) clinical level A-D and non-clinical level 1-2 within 10 days; and (2) clinical level E-I and non-clinical level 3-5 within 5 days; 3) Root cause analysis: reviewing clinical level E-I and non-clinical level 3-5 within 7 days; and 4) Register: bringing the results from the causal analysis (RCA) into the risk management account Risk Register.

3. Regarding the effectiveness, a number of incidents were reported and their root cause analysis (RCA) were reviewed increasing in 2020 (46.23%) at a high level of satisfaction.

          This study leads to develop a system to prevent and monitor risks and also prevent adverse events in patients. In addition, the system can help increase quality of the services.