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      What to do With Healthcare Incident Reporting Systems

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          Abstract

          Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems. These limitations include: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don’t generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. IRS do offer significant value; their value is found in the following: i) IRS can be used to identify local system hazards; ii) IRS can be used to aggregate experiences for uncommon conditions; iii) IRS can be used to share lessons within and across organizations; iv) IRS can be used to increase patient safety culture. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, report and investigate them well; v) convene with diverse stakeholders to enhance the value of IRS.

          Significance for public health

          Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. However, they are not the panacea that many believe them to be. They have several limitations that should be considered when utilizing them or interpreting their output: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don’t generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, do it well; v) convene with diverse stakeholders to enhance their value.

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          Most cited references18

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          Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review.

          To evaluate the performance of a routine incident reporting system in identifying patient safety incidents. Two stage retrospective review of patients' case notes and analysis of data submitted to the routine incident reporting system on the same patients. A large NHS hospital in England. 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). 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. 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. 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.
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              Comparison of methods for detecting medication errors in 36 hospitals and skilled-nursing facilities.

              The validity and cost-effectiveness of three methods for detecting medication errors were examined. A stratified random sample of 36 hospitals and skilled-nursing facilities in Colorado and Georgia was selected. Medication administration errors were detected by registered nurses (R.N.s), licensed practical nurses (L.P.N.s), and pharmacy technicians from these facilities using three methods: incident report review, chart review, and direct observation. Each dose evaluated was compared with the prescriber's order. Deviations were considered errors. Efficiency was measured by the time spent evaluating each dose. A pharmacist performed an independent determination of errors to assess the accuracy of each data collector. Clinical significance was judged by a panel of physicians. Observers detected 300 of 457 pharmacist-confirmed errors made on 2556 doses (11.7% error rate) compared with 17 errors detected by chart reviewers (0.7% error rate), and 1 error detected by incident report review (0.04% error rate). All errors detected involved the same 2556 doses. All chart reviewers and 7 of 10 observers achieved at least good comparability with the pharmacist's results. The mean cost of error detection per dose was $4.82 for direct observation and $0.63 for chart review. The technician was the least expensive observer at $2.87 per dose evaluated. R.N.s were the least expensive chart reviewers at $0.50 per dose. Of 457 errors, 35 (8%) were deemed potentially clinically significant; 71% of these were detected by direct observation. Direct observation was more efficient and accurate than reviewing charts and incident reports in detecting medication errors. Pharmacy technicians were more efficient and accurate than R.N.s and L.P.N.s in collecting data about medication errors.
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                Author and article information

                Journal
                J Public Health Res
                J Public Health Res
                JPHR
                Journal of Public Health Research
                PAGEPress Publications, Pavia, Italy
                2279-9028
                2279-9036
                01 December 2013
                01 December 2013
                : 2
                : 3
                : e27
                Affiliations
                Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine , Baltimore, MD, USA
                Author notes
                Correspondence: Julius Cuong Pham, Department of Emergency Medicine, The Johns Hopkins University School of Medicine, 5801 Smith Ave, Suite 220, Baltimore 21209, MD, USA. +1.410.614.9919 - +1.410.614.1776. jpham3@ 123456jhmi.edu

                Contributions: the authors contributed equally.

                Conflicts of interest: the authors declare no potential conflict of interests.

                Article
                10.4081/jphr.2013.e27
                4147750
                25170498
                6883e89e-c1a6-4075-a847-89dec4b89082
                ©Copyright J.C. Pham et al., 2013

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 01 November 2013
                : 01 November 2013
                Page count
                Figures: 1, Tables: 1, Equations: 0, References: 29, Pages: 6
                Categories
                Review

                incident reporting systems,healthcare
                incident reporting systems, healthcare

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