What is an Adverse Incident?
“Any event or circumstance that could haveor did lead to harm, loss or damage topeople, property, environment orreputation.”
This includes “near misses”
Significant Events, AI & SAI
•Significant Event: - Within Practice, discussed over coffee,specific to practice, solved by practice, no learning outsidePractice
•Adverse Incident: - Within/involving Practice, could happen toanother Practice, may/may not be solvable by Practice,potential learning for other practices (individual /trend)
•Serious Adverse incident: - As for AI but meets SAI criteria.
GDS examples of AI (single event)
Prescription pad goes missing
The same local anaesthetic cartridge is used for 2 Patients
A patient is admitted to hospital with a spreading oralinfection after receiving dental treatment
A dentist finds untreated caries in a patient recentlydischarged as orally fit by another dentist in the practice
Why report an Adverse Incident?
Learn from incidents
Share knowledge across practices
Prevent reoccurrence.
When should an adverseincident be reported?
It should be an immediate response to theoccurrence…don’t investigate first!
If the incident is related to the sudden orunexpected death of a patient then….within24 hours
All other adverse incidents should bereported within 72 hours
Adverse Incident Reporting Summary
Why report?
Learn from incidents
Share knowledge
Prevent reoccurrence.
Learning Culture – NOT Blame Culture !
Adverse Incident
“Any event or circumstance thatcould have or did lead to harm, lossor damage to people, property,environment or reputation.”