Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals

Abstract

Objectives: To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incidentreporting rates and change the types of incidents reported. Design, setting and participants: Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia. Main outcome measures: Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units. Results: The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10 000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p,0.001) and in emergency departments (EDs) (additional 39.5 reports/10 000 ED attendances; 95% CI 17.0 to 62.0, p,0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10 000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10 000 OBDs; 95% CI 23.9 to 94.1, p,0.001) and (c) anonymously (additional 20.2 reports/10 000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p,0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively). Conclusions: A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.

Retrospective Analysis of Opioid Medication Incidents Requiring Administration of Naloxone

“…21 A previous initiative to address some of these issues significantly increased the number of occurrence reports submitted over a variety of hospitals and units. 29 Acute care centres in Canada that wish to increase incident reporting may achieve a comparable increase through similar programming.…”

“…In previous surveys, reasons for under-reporting among health care providers were uncertainty about what should be reported and who should do the reporting, as well as concerns about implicating colleagues, legal ramifications, and time constraints. 21,29 Health care providers reported that they would be more likely to submit occurrence reports if they could receive regular feedback about the reported incidents and if they believed or witnessed that occurrence reporting changed patient care and system processes. 30 These providers would also be more likely to report if they could submit in an electronic format or if they were to receive further education to help determine what type of incident requires a report.…”

Enhancing safety culture and event reporting: Insights from clinicians and administrators

“…Second, despite a corporate policy on what and how to report safety events, an explanation of how corporate safety interventions or strategies are linked to individual accountability for safe care in daily work is recommended. Key to these efforts are including personal stories, using reminders, and making content relevant and user friendly for all intended audiences [4,13] . In turn, this should assist with embedding error wisdom [35] and reciprocal accountability [32][33][34] whereby there is a clear idea of what safety events are to be reported and acted on.…”

“…As part of the hospital's corporate safety plan, a multi-pronged approach to improving event reporting and safety culture was developed using recommendations from national organizations [11,12] and empirical work demonstrating the effectiveness of interventions (e.g. education and training, publications and newsletters, incentives and rewards to report safety events, and online networks) [1,[5][6][7][12][13][14][15][16] . SafetyNET was developed with a team of researchers, administrators, clinicians, and educators with expertise in patient safety and quality improvement.…”

Quantifying behavioural determinants relating to health professional reporting of medication errors: a cross-sectional survey using the Theoretical Domains Framework

“…Multimodal interventions may be required to promote behavioural change, particularly in areas such as emotions, a complex process that takes place over time at individual, population and organisational levels. Evans et al reported the evaluation of an intervention aimed at improving voluntary incident reporting in hospitals [23]. The intervention comprised providing intense education, a range of reporting options, changes in report management and enhanced feedback.…”