Building safer systems through critical occurrence reviews: nine years of learning

Area of Science:

• Healthcare Quality and Safety
• Patient Safety Research
• Risk Management in Hospitals

Background:

• The Hospital for Sick Children (SickKids) developed the term 'critical occurrence' to categorize serious adverse events.
• Existing definitions of critical incidents, such as those in Ontario's Public Hospitals Act, provide a framework for understanding these events.

Purpose of the Study:

• To define and delineate the scope of 'critical occurrences' within a hospital setting.
• To establish a standardized terminology for reporting and analyzing patient and staff safety events.

Main Methods:

• Conceptual development and definition of 'critical occurrence'.
• Comparison of the 'critical occurrence' definition with existing regulatory definitions (e.g., Regulation 965, Public Hospitals Act).

Main Results:

• A critical occurrence encompasses unexpected patient or staff outcomes, including death or major functional loss, unrelated to the natural course of illness.
• The definition includes breaches of legislation, such as the Personal Health Information Protection Act.
• Examples of critical occurrences include medication errors, wrong-site procedures, contaminated products, equipment malfunction, infections, and staff injuries.

Conclusions:

• The 'critical occurrence' framework provides a comprehensive approach to identifying and reporting significant safety events.
• Standardized definitions are crucial for improving patient safety and healthcare quality.
• This terminology supports better incident analysis and prevention strategies.