Strengths and weaknesses of the incident reporting system: An Italian experience

Abstract

One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients’ falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators’ education, no-blame culture promotion, and organizational adjustments may improve operators’ adherence to IRS. Providers do not willingly inform patients’ relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.

Medical errors, affected sites, and adverse consequences among patients in the orthopaedic department: Does age matter?

“…Additionally, it is equally vital to enhance physician-patient communication to prevent additional medical errors in the orthopaedic department. Generally speaking, verbal aggression toward the physicians or between patients has been the most reported events ( 32 ). Despite having identified the insufficient implementation of informed consent obligations as a challenge for orthopaedists ( 33 ), further analysis indicated that this challenge may be more frequent in adult and older adults patients, especially in the adult population.…”

“…In addition, the FDA created an analogous program called MedWatch to aid healthcare professionals in reporting adverse events, which aimed to help orthopaedic surgeons protect their patients (30). Other scholars believe that shifting the culture surrounding medical errors from blame to understanding and prevention could accomplish mutual benefits for patients and surgeons in orthopaedic departments (31).…”

Assessment of the organizational factors in incident management practices in healthcare: A tree augmented Naive Bayes model

“…Various incident management practices have been adopted to provide a collaborative strategy for incident reporting, investigation, and control in healthcare [ 13 , 14 ]. These practices outline organizational processes and fundamental principles that facilitate efficient and effective incident management for all types of risks [ 15 ].…”

“…These practices outline organizational processes and fundamental principles that facilitate efficient and effective incident management for all types of risks [ 15 ]. Incident reporting and investigation are integral aspects of effectively managing and responding to incidents [ 14 ]. Incident reporting plays a crucial role by providing vital information that shapes decision-making, resource allocation, analysis, and compliance.…”

Getting better: Staying ahead of the curve on patient safety

“…Benevento and colleagues analyzed 5 years of experience from their hospital's incident reporting system in Italy. 21 They found that underreporting was the main limitation of their system and proposed ways to increase health workers' reporting.…”