Can incident reporting improve safety? Healthcare practitioners' views of the effectiveness of incident reporting (original) (raw)
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2015
Patient safety has been on the research agenda since 2000, when unnecessary harm to patients in providers’ care came to light. In 2005, the improvements in patient safety fell short of expectations, and the patient safety research community recognized that the issues are more difficult to resolve than first thought. One of the tools to address this vexing problem has been voluntary incident reporting systems, although the literature has given incident reporting systems mixed reviews. This qualitative comparative case study comprises 85 semi-structured interviews in two separate divisions of a tertiary care hospital, General Internal Medicine (GIM) and Obstetrics and Neonatology (OBS/NEO). The main line of questioning concerned incident reporting; general views of patient safety were also sought. This is a thesis by publication. The thesis consists of a general introduction to patient safety, a literature review, a description of the methods and cases, followed by the manuscripts. Th...
Feedback from Reporting Patient Safety Incidents - Are Nhs Trusts Learning Lessons?
Journal of Health Services Research & Policy, 2010
For the study, first published in 2006, the researchers examined how well NHS organisations had attempted to use the information they gathered from adverse clinical incidents and whether they were learning from it. By looking at existing relevant research worldwide, interviewing experts, surveying NHS organizations (acute, community and ambulance), consulting health care and other high-risk industry safety experts and NHS risk managers, and investigating case studies of good practice, they developed a model to assess how ready NHS systems were to learn from incidents. This is known as Safety Action and Information Feedback from Incident Reporting (SAIFIR).
Medicine, 2018
The effectiveness of a hospital incident-reporting system (IRS) on improve patient safety is unclear. This study objective was to assess which implemented improvement actions after the analysis of the incidents reported were effective in reduce near-misses or adverse events.Patient safety incidents (PSIs), near misses and adverse events, notified to the IRS were analyzed by local clinical safety leaders (CSLs) who propose and implement improvement actions. The local CSLs received training workshops in patient safety and analysis tools. Following the notification of a PSI in the IRS, prospective real-time observations with external staff were planned to record and rated the frequency of that PSI. This methodology was repeated after the implementation of the improvement actions.Ultimately, 1983 PSIs were identified. Surgery theaters, emergency departments, intensive care units, and general adult care units comprised 82% of all PSIs. The PSI rate increased from 0.39 to 3.4 per 1000 sta...
Incidents reporting: barriers and strategies to promote safety culture
Revista da Escola de Enfermagem da U S P, 2018
The purpose was to identify the barriers of underreporting, the factors that promote motivation of health professionals to report, and strategies to enhance incidents reporting. Group conversations were carried out within a hospital multidisciplinary team. A mediator stimulated reflection among the subjects about the theme. Sixty-five health professionals were enrolled. Complacency and ambition were barriers exceeded. Lack of responsibility about culture of reporting was the new barrier observed. There is a belief only nurses should report incidents. The strategies related to motivation reported were: feedback; educational intervention with hospital staff; and simplified tools for reporting (electronic or manual), which allow filling critical information and traceability of management risk team to improve the quality of report. Ordinary and practical strategies should be developed to optimize incidents reporting, to make people aware about their responsibilities about the culture of...
Journal of Hospital Administration, 2020
Objective: This review summarizes and synthesizes the evidence on follow-up activities regarding patient safety incidents reported in hospitals. Methods: Peer-reviewed papers were retrieved with electronic searches from CINAHL, Web of Science, PubMed and Scopus databases and with manual searches in most relevant journals and in the reference lists of included studies, limiting searches to papers published in English between 2014 and 2018. A systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Two authors extracted the data following a predefined extraction form. Results: All together 16 studies were selected for analysis. All studies described incidents and gave insight into problems, risks and unsafe situations which were responded to with recommended improvements. Recommended improvements in response to incidents involved guidelines, staff training, technical improvements and general safety improvements. Only five studies reported feedback and knowledge dissemination activities, referring to meetings, written support and visual support. Conclusions: Limited research has described the systematic use of report outcomes for knowledge application in organizations. However, the development of patient safety requires that reported incidents are responded to by knowledge application within feedback and knowledge dissemination activities. Therefore, healthcare professionals need to have sufficient competences in patient safety, and more research is needed on the content and effectiveness of the responding activities.
Using Incident Reporting to Improve Patient Safety
Journal of Patient Safety, 2007
Objectives: The objectives of this paper are to discuss the role of risk analysis and event taxonomies in patient safety reporting systems (PSRSs) and present a conceptual model that supports the use of reporting and analysis to help guide patient safety improvement efforts. Methods: This research involves an analysis of the methodologies being used to use medical incident reports to improve patient safety. Areas discussed are risk analysis, incident-reporting contributions to risk measures, and event taxonomies for health care procedures. Results: Incidents reported in PSRSs are subject to selection bias, have unknown denominators, and require standardized taxonomies for numerators. PSRSs provide a mechanism to identify and learn from mistakes. A conceptual model for using a PSRS to improve safety is proposed. This model includes 4 major elements: (1) recognition and reporting of events, (2) event analysis, (3) analysis of results produced, and (4) process changes developed and implemented. The central themes of this model are education and learning to engage staff and organizations and to affect behavioral change. Conclusions: PSRS is a widely recommended as a strategy to address the important problem of patient safety. Most efforts have focused on developing reporting systems and collecting incident data. We are now faced with deciding how best to analyze and report information back to stakeholders and what process changes will best decrease harm. We outline a comprehensive conceptual model to help realize the full potential of reporting systems in patient safety improvement efforts.
British Medical Journal, 2007
Objective To evaluate the performance of a routine incident reporting system in identifying patient safety incidents. Design Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients. Setting A large NHS hospital in England. Population 1006 hospital admissions between January and May 2004: surgery (n = 311), general medicine (n = 251), elderly care (n = 184), orthopaedics (n = 131), urology (n = 61), and three other specialties (n = 68). Main outcome measures Proportion of admissions with at least one patient safety incident; proportion and type of patient safety incidents missed by routine incident reporting and case note review methods. Results 324 patient safety incidents were identified in 230/1006 admissions (22.9%; 95% confidence interval 20.3% to 25.5%). 270 (83%) patient safety incidents were identified by case note review only, 21 (7%) by the routine reporting system only, and 33 (10%) by both methods. 110 admissions (10.9%; 9.0% to 12.8%) had at least one patient safety incident resulting in patient harm, all of which were detected by the case note review and six (5%) by the reporting system. Conclusion The routine incident reporting system may be poor at identifying patient safety incidents, particularly those resulting in harm. Structured case note review may have a useful role in surveillance of routine incident reporting and associated quality improvement programmes. BMJ BMJ Online First
Journal of Health Services Research & Policy
Objectives To compare a new co-designed, patient incident reporting tool with three established methods of detecting patient safety incidents and identify if the same incidents are recorded across methods. Method Trained research staff collected data from inpatients in nine wards in one university teaching hospital during their stay. Those classified as patient safety incidents were retained. We then searched for patient safety incidents in the corresponding patient case notes, staff incident reports and reports to the Patient Advice and Liaison Service specific to the study wards. Results In the nine wards, 329 patients were recruited to the study, of which 77 provided 155 patient reports. From these, 68 patient safety incidents were identified. Eight of these were also identified from case note review, five were also identified in incident reports, and two were also found in the records of a local Patient Advice and Liaison Service. Reports of patients covered a range of events fr...
Attitudes of doctors and nurses towards incident reporting: a qualitative analysis
The Medical journal of Australia, 2004
Objectives: (i) To examine attitudes of medical and nursing staff towards reporting incidents (adverse events and near-misses), and (ii) to identify measures to facilitate incident reporting. Design: Qualitative study. In March 2002, semistructured questions were administered to five focus groups -one each for consultants, registrars, resident medical officers, senior nurses, and junior nurses. Participants and setting: 14 medical and 19 nursing staff recruited using purposive sampling from three metropolitan public hospitals in Adelaide, South Australia. Main outcome measures: Attitudes and barriers to incident reporting; differences in reporting behaviour between disciplines; how to facilitate incident reporting. Results: Cultural differences between doctors and nurses, identified using Triandis' theory of social behaviour, were found to underpin attitudes to incident reporting. Nurses reported more habitually than doctors due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents "in-house" and was less reliant on directives. Common barriers to reporting incidents included time constraints, unsatisfactory processes, deficiencies in knowledge, cultural norms, inadequate feedback, beliefs about risk, and a perceived lack of value in the process.