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

Abstract

Objective: This review summarizes and synthesizes the evidence on follow-up activities regarding patient safety incidents reported in hospitals.Methods: Peer-reviewed papers were retrieved with electronic searches from CINAHL, Web of Science, PubMed and Scopus databases and with manual searches in most relevant journals and in the reference lists of included studies, limiting searches to papers published in English between 2014 and 2018. A systematic review was conducted in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Two authors extracted the data following a predefined extraction form.Results: All together 16 studies were selected for analysis. All studies described incidents and gave insight into problems, risks and unsafe situations which were responded to with recommended improvements. Recommended improvements in response to incidents involved guidelines, staff training, technical improvements and general safety improvements. Only five studies reported feedback and knowledge dissemination activities, referring to meetings, written support and visual support.Conclusions: Limited research has described the systematic use of report outcomes for knowledge application in organizations. However, the development of patient safety requires that reported incidents are responded to by knowledge application within feedback and knowledge dissemination activities. Therefore, healthcare professionals need to have sufficient competences in patient safety, and more research is needed on the content and effectiveness of the responding activities.

Planned improvement actions based on patient safety incident reports in Estonian hospitals: a document analysis

“…In the current study, the proportion of incidents related to medications were less reported as compared with the previously published studies. 1 13 22–24 It is noteworthy that there is no previous information on the level and reasons for medication incidents in Estonia. In the previous studies, the low level of medication-related incident reporting was explained as a lack of clear definitions of medication error, 25 26 a lack of feedback on reporting 3 8 26 and a reporter’s previous experience with such kind of incidents.…”

“…Based on the WHO conceptual framework for patient safety 2 19 and previously published literature, 1 7 8 we developed a data extraction form for data collection. The extraction form was consisted of three parts.…”

“…During the last 15 years, incident reporting systems (IRSs) have been established in hospitals for identifying patient safety problems. 1 2 IRSs are recognised as a system approach to detect, review and analyse safety incidents. They are used to evaluate the gained information and to implement the changes based on the planned improvement actions.…”

“…Even though IRSs have been established in hospitals globally, 1 2 their implementation is variable. 1 7 8 In Estonia, an initiative of patient safety has emerged as a focus in healthcare and society since the last decade, and therefore, is a relatively new concept.…”

“…Even though IRSs have been established in hospitals globally, 1 2 their implementation is variable. 1 7 8 In Estonia, an initiative of patient safety has emerged as a focus in healthcare and society since the last decade, and therefore, is a relatively new concept. Hospitals are obligated to document adverse events such as transfusion reactions, postoperative wound infections, pressure ulcers, patient fall and transfer-related incidents with an outcome of patient harm, and adverse effects that occurred during the use of medicinal products.…”