Disclosure of Patient Safety Incidents

Each RT has an ethical, professional, and legal responsibility to provide full and frank disclosure of all patient safety incidents, that result in harm or have the potential for future harm, as soon as reasonably possible. In addition, amendments to the Hospital Management regulation made under the Public Hospitals Act now requires healthcare administrators (e.g., hospital administration) to establish a system for ensuring prompt disclosure of every critical incident to all affected parties. (O.Reg.423/07, 2007) Patient safety events are generally classified as near miss, no harm incident, or harmful incident. While all incidents need to be appropriately reviewed to understand the contributory causes and implement future prevention policies, typically, near misses are not disclosed to patients or families.

A RT on nights is called to attend to an infant whose ETT has become separated from the 15mm connector. The tube has migrated into the infant’s airway and the RT had to use Magill forceps to retrieve it. The infant experiences minimal bleeding and a brief period of de-saturation. It was apparent that the RT on days had not secured the ETT properly and this had likely led to the disconnection being obscured until it was too late. Is this a critical incident and what should the RT do regarding the co-worker’s error?

An RT performed a blood gas on a patient on the stroke unit. When they were finished, they did not put the bed rail up, and as they were preparing the sample to go the the lab, the patient fell onto the floor and broke their hip.

What are the next steps for the RT?