One of the most important aspects of being a healthcare provider is to “Do no harm” as outlined in the Hippocratic Oath. Often we have to weigh risks and benefits of our treatments that we know may cause minor harm including surgery and the side effects of medications of medications. But what should we do when there are unintended events that affect a patient? Do you yell at the person who made the mistake? Do you report it to the person’s supervisor? What do you do when you realize that a mistake was about to occur but was caught in time?
Depending on your role in the hospital, it may be appropriate to discuss the event with the team member who made the mistake or the near-miss in a private, professional setting. Or it may be more appropriate to bring it to the attention to the supervisor for the area. But in all of these situations, a MIDAS Incident Reporting Form should be completed.
The MIDAS tool is an easy-to-use form on the Citrix desktop that allows you to submit details of various kinds of events or near-misses including safety events, patient care events, development of a pressure ulcer, a patient fall, etc. Each and every submission will be reviewed by the hospital’s council for patient safety. And while the submission you make can be done anonymously, the investigation may be improved if the reporter can be contacted to give additional details. Remember, the Compliance Office does not permit retaliation in the workplace, and any instance of retaliation can be reported to the Resident Council, submitted as anonymous feedback on this website, or can be called into the DMC Compliance Hotline (1-800-8ETHICS).
Submitted a MIDAS report is simple and takes less than 5 minutes. The following images and instructions will demonstrate a basic submission of an event in which a medication was given to the wrong patient.
1. First open the MIDAS reporting system by selecting the appropriate icon on the Citrix Desktop
2. Next, select the event type that most accurately fits the type of incident that occurred.
3. Choose the facility where the event took place from the drop down menu
5. Type in the patient’s first and last names and then press “Lookup”. A list of encounters will appear. Make sure to select the correct patient by verifying the birth date. Select the encounter during which the event took place — if the patient is an inpatient, the current floor and room of the patient should appear in the encounter information. The press “OK”
6. Enter the approximate time the event occurred. Select the most appropriate description of the event from the drop down menu. Further description can be added later on.
7. Enter more details of the event as appropriate. It is okay to be brief as this event will be investigated including a chart review. The information about why the patient is admitted will be accessible. However, if there is other information that you think may not be found in the chart, please include it. Indicate if the incident reached the patient (or was it a near-miss?). Select the level of harm that occurred to the patient as a result of the incident.
8. Indicate if there were any witnesses. Select the box that indicates that you are aware the information will be accessible by the patient safety committees that are responsible for investigating. Identify who the source of the information was (family, nurse, PCA, etc) and then identify your role (nurse, intern, etc). You can choose to make the submission anonymous at this point. Select “Submit” to complete the form.
9. The form is now complete.