Adverse events, errors, and near misses must be identified and classified in order to evaluate, look for trends and make overall improvements in individual practice and/or systems of care. One way these events are captured and reported is through incident/safety reports.
Incident/safety reports are considered an internal type of reporting system and are the most common way of measuring errors. Traditionally the process looks like this: a healthcare provider completes a form (either paper or computerized system), the event is categorized by error type (medication error, patient fall, shoulder dystocia, postpartum hemorrhage, etc.) and level of harm is determined. Level of harm is broken down into events that don’t reach the patient (near miss), reach the patient and cause minimal or no harm (precursor safety events), and last those that reach the patient causing death, moderate-severe permanent harm, or significant temporary harm (serious safety event). Events are reviewed and investigated by management, which could be nursing and physician leadership, safety officers, and risk management.
The goal is to identify any gaps in care (i.e. was policy/guidelines/standard process followed) and then fix the identified issues. For example, perhaps there are a number of incident reports that identify transportation staff leaving patients with the bed in a high position and side rails down in unsafe conditions. These are near miss events because fall precautions are not being followed, leaving patients at high risk for falls. This can be improved by collaboration and education with the transportation team on the proper process/precautions to use before patient harm occurs.
There are some disadvantages to the incident/safety reporting system. This method is voluntary and therefore limited by staff willingness to input events. They can also be done anonymously, which is good if there is concern for retaliation but difficult if there is a lesson learned that needs to circle back to the staff involved. Typically incident reports are completed more frequently by nurses than other disciplines. Unfortunately, few residents and doctors use this mechanism to report errors, leading to gaps in safety/quality issues with respect to this group.
Reporting can also be influenced by other factors. Completing the report can take a significant amount of time (not easy at the end of a long shift). There may be a fear of retaliation, or lack of realizing a need to report errors that don’t result in harm. The amount of reporting may also be influenced by the current safety culture. For example, a strong safety culture that encourages reporting and learning from events & errors, and protects confidentiality may have a robust reporting system. The number of reports, however, is not an indicator of overall safety. An increase in reports can either reflect an environment or system that is less safe or an increase in staff being comfortable reporting and knowing this will generate meaningful change.
In summary, incident/safety reports are one method of identifying & reporting safety events, allowing for an opportunity to find and fix problems and create safer patient care environments.
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References
Wachter, R. M. (2008). Understanding patient safety. McGraw Hill.
Fondahn, E., Lane, M., & Vannucci, A. (2016). The Washington Manual of patient safety and quality improvement. Wolters Kluwer.