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

Fukami, T.; Uemura, Masakazu; Nagao, Yoshimasa

doi:10.1186/s13037-020-00240-y

Cited by 20 publications

(19 citation statements)

References 11 publications

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“…In addition, hospital-wide reporting of near-miss events is also significant because these events are precursors of adverse events. After identifying various clinical departments' high-risk areas, the next step should be to analyze the root cause of incidents, especially those reported by doctors, and intervene appropriately to improve healthcare quality [ 4 ]. This aspect should contribute directly to safer care and overall enforcement of the hospital's patient safety culture, particularly because reports from doctors are overwhelmingly more severe than those from other occupations; this means that hospitals cannot accurately ascertain adverse events unless doctors submit their reports.…”

Section: Patient Safety Management During Critical Situationsmentioning

confidence: 99%

The comprehensive double loop activities for patient safety management

Fukami

Nagao

Uemura

2022

Annals of Medicine &Amp; Surgery

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Section: Patient Safety Management During Critical Situationsmentioning

confidence: 99%

The comprehensive double loop activities for patient safety management

Fukami

Nagao

Uemura

2022

Annals of Medicine &Amp; Surgery

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“…NUH is a 1080-bed hospital, and the rst university hospital in Japan to be accredited by the Joint Commission International. NUH has an independent department that undertakes patient safety management, including the incident reporting system [25]. When encountering an incident, all employees are eligible to report anonymously through the electronic health record system, which is in Japanese.…”

Section: Data Sourcesmentioning

confidence: 99%

“…Levels 0 and 1 describe near-miss events and levels 2 to 5 are de ned as adverse events. Severe incidents are considered to be those between levels 3b and 5, involving outcomes such as sustained treatment required, possible disability, prolonged hospitalization, or death [25,27]. All employees can access the NUHCJ classi cation in a pocket-sized patient safety manual that they are required to carry.…”

Section: Data Sourcesmentioning

confidence: 99%

Development and Validation of a Novel Scoring System to Quantify the Severity of Incident Reports Using Machine Learning: An exploratory research study

Uematsu

Uemura

Kurihara

et al. 2022

Preprint

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Incident reporting systems have been widely adopted to collect information about patient safety incidents. The value of incident reports often lies in the free-text section, but this is often inadequately processed. We developed a novel scoring system that uses machine learning to assess the severity of an incident using the semantic characteristics of text in incident reports. We retrospectively analyzed free-text data extracted from incident reports from between January 2012 and September 2021 at Nagoya University Hospital, Aichi, Japan. The sample was randomly allocated into a training dataset and validation dataset. Morphological analysis was used to segment terms using the training dataset. We calculated a severity term score, a severity report score and severity group score, by the report volume size. We then compared these with conventional severity classifications by patient safety experts and reporters. We allocated 96,082 incident reports into two groups. From the 48,041 reports in the training dataset, 1,802 severity term scores were calculated. There was a significant difference in severity report score between reports categorized as severe and not severe by experts (95% confidence interval [CI] − 0.83 to − 0.80, p < 0.001). Severity group scores were positively associated with severity ratings from experts and reporters, with correlation coefficients of 0.73 (95% CI 0.63–0.80, p < 0.001) and 0.79 (95% CI 0.71–0.85, p < 0.001) for all departments. Our severity scoring system using machine learning could contribute to improved organizational patient safety.

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“…One group found that the types of safety incidents reported by physicians at their hospital were of greater severity with more serious consequences, compared with reports submitted by colleagues from a different health discipline. 10 …”

Section: Introductionmentioning

confidence: 99%

Improving incident reporting among physicians at south health campus hospital

et al. 2022

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Reports of adverse events and near-misses provide the opportunity to learn about latent (systems) errors. However, voluntary incident reporting systems are underused by physicians. While reports submitted by nursing staff relate to common hazards such as medication administration or falls, physicians have broader exposure to patients’ entire hospital journey. Reports by physicians have the potential to uncover more serious errors that could span multiple departments and layers of personnel. Organisational safety culture thrives when all staff are represented and feel empowered to share safety concerns.At the South Health Campus (SHC) Hospital in Calgary, Alberta, Canada, the baseline proportion of physician-submitted reports within our site’s Reporting and Learning System (RLS) from July 2013 to December 2016 was 1.12%. We implemented an intervention to double the proportion of physician-submitted RLS reports, using quality improvement methods.Focus groups identified lack of experience with the RLS system, lack of feedback or closure after an RLS submission, and apprehensions about disclosing the incident to the affected patient as barriers to physician submission. Accordingly, the intervention involved direct responses from physician leadership to each physician-submitted RLS report, multimedia demonstrations of efficient RLS submission to physician groups and medical learners, and linkage to materials on safe disclosures. Effectiveness was assessed using a controlled before-and-after design, comparing SHC with the rest of Calgary and with the rest of Alberta.Following the intervention, the proportion of RLS reports that were physician submitted increased to 2.65% (OR 2.42 [95% CI 1.96 to 3.02], p<0.001), sustained over the following 4 years. While an increase was observed for the rest of Calgary, it was smaller (OR 1.27 [1.15 to 1.40], p<0.001). A decrease in the odds of physician submission was observed for the rest of Alberta. Differences between sites were significant (p<0.001).Overall, we found that physician-submitted incident reports can be increased and sustained over time if submitters receive personalised feedback by a physician safety leader. At our site, reports submitted by physicians have been valuable in uncovering complex systems issues that may not have been readily apparent.

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

Cited by 20 publications

References 11 publications

The comprehensive double loop activities for patient safety management

The comprehensive double loop activities for patient safety management

Development and Validation of a Novel Scoring System to Quantify the Severity of Incident Reports Using Machine Learning: An exploratory research study

Improving incident reporting among physicians at south health campus hospital

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