Effectiveness and limitations of an incident-reporting system analyzed by local clinical safety leaders in a tertiary hospital

Abstract

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Reporting and responding to patient safety incidents based on data from hospitals’ reporting systems: A systematic review

“…[15,19,21] Three studies reported adverse drug events and reactions (side effect/interaction) as medication-related incidents. [13,18,27] Medication-related incidents were the highestrated [14,19,24] or second highest-rated concern [20,21,26,27] in seven studies out of twelve. Five studies reported general trends in medication-related incidents without describing them in detail.…”

“…Sixteen (n = 16) papers were included in the final analysis. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] We conducted the study selections with three researchers independently examining each paper phase by phase. Discussions were held to compare the selections, and in the case of disagreement, the decision about inclusion or exclusion was carried out through consensus.…”

“…Pitkä nen et al 2016 [25] Electronic/ Anonymous [26] Electronic/ Anonymous [27] Paper/ Non-anonymous [28] Electronic…”

“…[16, 18-21, 23, 24] Staff who did not know the guidelines caused faulty monitoring, treatment or procedures. [16,18,20,28] Mistakes were made with patient identification or verification [14,17,18,20,26] and with obtaining a patient's informed consent. [14,23,24,26] For example, a blank informed consent form was signed by a patient, or no anaesthesia or surgical consent forms were signed at all, which resulted in the cancellation of a procedure, or a procedure was completed without documented patient consent.…”

Significance of incident reports by medical doctors for organizational transparency and driving forces for patient safety

“…An incident-reporting system is an organized approach to reporting near misses or adverse events to enable improvement [2]. An incidentreporting system is a voluntary, anonymous, confidential electronic system that allows the reporting of incidents and adverse events for analysis by experts in quality improvement and patient safety [3,4,5]. Although this system might well improve patient safety by reducing the risk of adverse events, it has many obvious limitations: reports are sometimes entirely subjective and therefore unfair, are not comparable between hospitals, and carry unacknowledged bias [6,7].…”