The following principles emphasize the purpose and characteristics of BCPSLS data and promote consistency across data users.
It is essential that users of BCPSLS data understand and represent it appropriately.
Inappropriate presentations of BCPSLS data may result in misdirected efforts or failed projects, and discourage reporting.
What BCPSLS data tells us
It reflects the safety reporting culture in an organization.
It shows the most frequent types of reported patient safety incidents at provincial, health authority and local levels.
It shows which types of patient safety incidents are reported as most harmful, at provincial, health authority and local levels.
It helps us to understand how patient safety incidents happen.
It shows how incident reporting patterns change over time by degree of harm, by category and by care setting or organization.
What BCPSLS data does NOT tell us
It does not provide the actual number of patient safety incidents occurring in BC or in a particular organization.
It does not provide information on the full history and characteristics of patients involved in patient safety incidents.
It does not tell us if an organization is safe or unsafe.
It does not show an organization’s level of compliance with safety guidelines or practices.
It does not measure the efficacy of specific safety initiatives.
Added to make initial state appear closed
Actual vs. reported numbers
BCPSLS does not provide the actual number of patient safety incidents occurring in BC.
The BCPSLS database is an accurate source of incidents reported, rather than an imperfect source of actual incident data.
BCPSLS data users can help to ensure that this is understood by always referring to ‘reported’ patient safety incidents in reports, tables and figures.
A number of things can affect what is recognized as an incident. These include:
- the maturity of an individual’s or organization’s safety processes and culture
- new treatments and procedures
- changing standards of accepted clinical practice
- publications or campaigns raising awareness of under-recognized risks
- the effectiveness of local systems for seeking out incidents that would otherwise have gone undetected through case record review and audit
Incidents, not errors
‘Patient safety incident’ is not a synonym for error.
BCPSLS data includes:
- reports of harm unrelated to errors, such as adverse reactions to medication that could not have been anticipated or prevented
- situations with potential for causing harm that staff recognize and report before they result in error, such as hazards and near misses
- process problems that are pervasive in the healthcare system
- negative outcomes for patients that warrant investigation but do not involve errors
BCPSLS data users can help to ensure that this difference is understood by referring to BCPSLS data as ‘reported patient safety incidents’, or just ‘reported incidents’ (in contexts where patient safety is implicit), instead of ‘errors’.
BCPSLS is a dynamic reporting system and the number of incidents reported as occurring at any point in time may increase as more incidents are reported.
Incident classification, particularly fields related to categorization and harm, can also change as local investigations progress and incident reports are updated.
Therefore, the date of the data extraction should always be included on tables and chart references.
Trends over time
Changes to reporting requirements often result in changes to data series over time.
When looking at the data, consider:
- changes in reporting requirements
- changes in guidance on reporting in BCPSLS
- organizational change, as organizations take time to mature and set up systems and processes, which can impact reporting
When comparing BCPSLS data across time periods, it is important to compare data with the same time period in the previous year(s) to take into account known ‘incident seasonality’ in the data.
Research suggests healthcare activity and the types of conditions requiring treatment relate to time of year and these changes may affect incident reporting.
Therefore, when reviewing changes over time, we recommend that:
- proportions or percentages are used rather than actual numbers
- either the same time period in the previous year or a full year’s worth of data are used
- it is checked that any ‘change/difference’ is not caused by new or amended reporting requirements or organizational restructuring
We encourage reporters to report patient safety incidents in BCPSLS as soon as they are discovered and without delay.
In practice, there may be a delay between an incident occurring and being reported in BCPSLS.
So, a search using the date the incident occurred may return different results from one search to the next as reports of incidents that occurred at an earlier date are added and meet the search criteria.
To avoid this problem, all BCPSLS data users should search for records using the reported date, which is generated by the system software and read-only, meaning it cannot be modified after a report is submitted and no new reports can be submitted after the fact.
Degree of harm = 5 (Death)
Although the relationship of patient safety incident to the outcome of death in BCPSLS would imply that the death is directly attributable to the patient safety incident, mortality research has identified that this is rarely clear cut, and incident handlers often have to make a judgement call.
BCPSLS data users can help ensure this is understood by not summarizing reported degree of harm with terms such as ‘causing’ death except where this is justified and documented after investigation.
For more information
Contact BCPSLS Central Office by email at firstname.lastname@example.org or by phone at 604.877-6420.
Data principles adapted from NHS Improvement, National Reporting and Learning System data principles, December 2016.