Abstract

Background: A district nurse must be able to describe a situation and critically analyze. Risks can be discerned and identified and take appropriate actions and evaluate them. Risks in health care are made visible through incident reports. Paying attention to events that have already occurred can help prevent these mistakes from recurring.

Aim: The aim of the study was to investigate the number and nature of patient-related events in incidentreports and their scope in two primary care areas.

Method: The study had a qualitative approach and descriptive design. The data collection was done through incidentreports and the described event was analyzed using qualitative content analysis.

Result: The number of incident reports was on average 3.20 per 1000 registered patients in the two primary care areas in 2017. The 243 were divided into three different types; incoming, internal and outgoing. The data analysis resulted in six categories under each type. Common categories for all incident reports were; Lack of information transfer, Pharmaceutical responsibility, Incorrect assessment and Referral handling, however with addition Sample handling on incoming and Administration on internal and outgoing. Lack of responsibility was found on internal and outgoing. Coordination took place on incoming and outgoing. Incorrect referrals only appeared among the incoming and the category of insufficient staffing was found in the internals. The categories contain a description of the patient-related events that led to a discrepancy report.

Conclusion: The extent of incident reports shows that relatively few incidentreports are written in primary care. Most of the events described affect the patient indirectly through incorrect referral management or lack of information transfer between different units. Improvement potential is great by training staff to understand the importance of incident reporting and to take part in events that have already occurred to learn from past mistakes.

Keywords: district nurse, care process, incident report, patient safety, primary care