Mapping the limits of safety reporting systems in health care —what lessons can we actually learn?
- 20 June 2011
- journal article
- health care
- Published by Wiley in The Medical Journal of Australia
- Vol. 194 (12), 635-639
- https://doi.org/10.5694/j.1326-5377.2011.tb03146.x
Abstract
Objectives: To assess the utility of Australian health care incident reporting systems and determine the depth of information available within a typical system. Design and setting: Incidents relating to patient misidentification occurring between 2004 and 2008 were selected from a sample extracted from a number of Australian health services’ incident reporting systems using a manual search function. Main outcome measures: Incident type, aetiology (error type) and recovery (error‐detection mechanism). Analyses were performed to determine category saturation. Results: All 487 selected incidents could be classified according to incident type. The most prevalent incident type was medication being administered to the wrong patient (25.7%, 125), followed by incidents where a procedure was performed on the wrong patient (15.2%, 74) and incidents where an order for pathology or medical imaging was mislabelled (7.0%, 34). Category saturation was achieved quickly, with about half the total number of incident types identified in the first 13.5% of the incidents. All 43 incident types were classified within 76.2% of the dataset. Fifty‐two incident reports (10.7%) included sufficient information to classify specific incident aetiology, and 288 reports (59.1%) had sufficient detailed information to classify a specific incident recovery mechanism. Conclusions: Incident reporting systems enable the classification of the surface features of an incident and identify common incident types. However, current systems provide little useful information on the underlying aetiology or incident recovery functions. Our study highlights several limitations of incident reporting systems, and provides guidance for improving the use of such systems in quality and safety improvement.Keywords
This publication has 15 references indexed in Scilit:
- Attitudes toward the large-scale implementation of an incident reporting systemInternational Journal for Quality in Health Care, 2008
- An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classificationBMJ Quality & Safety, 2006
- Error detection: A study in anaesthesiaErgonomics, 2006
- Error recovery in a hospital pharmacyErgonomics, 2006
- Five Years After To Err Is HumanJAMA, 2005
- Are the risks of hospital practice adequately recognised by incident reporting?Quality and Safety in Health Care, 2005
- Learning from failure in health care: frequent opportunities, pervasive barriersQuality and Safety in Health Care, 2004
- FMEA and RCA: the mantras; of modern risk managementMaterials, 2004
- Setting priorities for patient safetyQuality and Safety in Health Care, 2002
- Continuous Improvement as an Ideal in Health CareNew England Journal of Medicine, 1989