Learning From Incident Reporting? Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care

Abstract

Objectives Incident reporting (IR) systems have the potential to improve patient safety if they enable learning from the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council. Methods The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence. Results Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline. Conclusions The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.

Understanding the Nature, Contributing Factors, and Corrective Actions of Medication Administration Errors: Insights from Saudi Arabia

“…[7,16,28,49] However, a recent study conducted revealed that over half of the adverse drug events were significant (52.7%), with 37.1% being serious, 9% life-threatening, and 3% fatal. [28] Study results delineated that staff factors contributing to MAEs (e.g., staff not following policies and procedures [14,42] and heavy workloads [27] ) are similar to other results in the literature. This study also elucidated inadequate assessment as contributing to MAEs.…”

“…This study also elucidated inadequate assessment as contributing to MAEs. The second most common factor contributing to MAEs, ineffective communication, also echoes other studies that have reported miscommunication, including between healthcare providers [3,27,34,37,42] and patients and inadequate records. [3] For example, in one study, causes attributed to communication and information (errors involving misunderstanding during handovers and insufficiently explicit information/communication) represented 20% of the 448 causes.…”

“…[2] Although learning from reported medication errors is acknowledged as a key to ensuring patient safety, the focus of research to date has not been on how or to what extent voluntary reporting systems can yield appropriate learning at individual and organizational levels. [27] Research has indicated that insufficient information about the nature and incidence of adverse events has hindered the development of preventative strategies to improve safety. [22,28] For example, research efforts in countries in the Middle East have been limited and focused on reporting on the incidence, type, and contributing factors and to a lesser extent on the preventability and severity of medication errors.…”

Patient and healthcare worker safety risks and injuries. Learning from incident reporting

“…As shown in Table 1, the incident reports provided the required information indicating good quality of the data and thus strengthening the validity of the analysis. Furthermore, data from IRSs can yield learning at the organisational and individual levels as previously suggested [19]. The main analysis focussed on the free-text section, which might capture the true value of the reports [18].…”

“…Reporting rates are important, but they are probably inaccurate as an indicator of the safety of a hospital [18]. Instead, there is a trend towards how IRSs can result in learning at the organisational and individual levels [19]. Previous studies have used data from IRSs regarding mainly patients [18][19][20][21]; a few have focussed on HCWs, but rarely have they explored IRS data including both patient and HCW incidents.…”