Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human’
Top Cited Papers
- 27 July 2015
- journal article
- research article
- Published by BMJ in BMJ Quality & Safety
- Vol. 25 (2), 92-99
- https://doi.org/10.1136/bmjqs-2015-004405
Abstract
One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget.Keywords
This publication has 27 references indexed in Scilit:
- Comparing Process- and Outcome-Oriented Approaches to Voluntary Incident Reporting in Two HospitalsThe Joint Commission Journal on Quality and Patient Safety, 2009
- Adverse event reporting systems and safer healthcareQuality and Safety in Health Care, 2009
- Adverse-event-reporting practices by US hospitals: results of a national surveyQuality and Safety in Health Care, 2008
- Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note reviewBMJ, 2006
- The development of the National Reporting and Learning System in England and Wales, 2001–2005The Medical Journal of Australia, 2006
- Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system--is this the right model?Quality and Safety in Health Care, 2002
- Adverse events in British hospitals: preliminary retrospective record reviewBMJ, 2001
- The Quality in Australian Health Care StudyThe Medical Journal of Australia, 1995
- The Incident Reporting System Does Not Detect Adverse Drug Events: A Problem for Quality ImprovementThe Joint Commission Journal on Quality Improvement, 1995
- The Nature of Adverse Events in Hospitalized PatientsNew England Journal of Medicine, 1991