Establishing a global learning community for incident-reporting systems

The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231, USA.
Quality and Safety in Health Care (Impact Factor: 2.16). 10/2010; 19(5):446-51. DOI: 10.1136/qshc.2009.037739
Source: PubMed


Background Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation.
Discussion Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.

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Available from: Albert W Wu, Feb 16, 2015
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    • "An increased rate of reporting, whereas in itself could imply that the culture of patient safety is improving, on its own is of limited value. The National Patient Safety Agency had 158 incidents reported in 2003 and to date has over 7 million incidents reported to it.27,28 Paradoxically, despite the large number of incident reports received by the NRLS, reporting systems have been shown to detect only about 6% of adverse events found by a systematic review of records.29 Indeed, it has been argued that national reporting systems are of great importance at identifying rare events, but of limited use in analyzing trends or acting as measurements of patient safety30 It is commendable that several solutions have been provided in the form of alerts and rapid responses.11 "
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    ABSTRACT: With scientific and technological advances, the practice of orthopedic surgery has transformed the lives of millions worldwide. Such successes however have a downside; not only is the provision of comprehensive orthopedic care becoming a fiscal challenge to policy-makers and funders, concerns are also being raised about the extent of the associated iatrogenic harm. The National Reporting and Learning System (NRLS) in England and Wales is an underused resource which collects intelligence from reports about health care error. Using methods akin to case-control methodology, we have identified a method of prioritizing the areas of a national database of errors that have the greatest propensity for harm. Our findings are presented using odds ratios (ORs) and 95% confidence intervals (CIs). The largest proportion of surgical patient safety incidents reported to the NRLS was from the trauma and orthopedics specialty, 48,095/163,595 (29.4%). Of those, 14,482/48,095 (30.1%) resulted in iatrogenic harm to the patient and 71/48,095 (0.15%) resulted in death. The leading types of errors associated with harm involved the implementation of care and on-going monitoring (OR 5.94, 95% CI 5.53, 6.38); self-harming behavior of patients in hospitals (OR 2.14, 95% CI 1.45, 3.18); and infection control (OR 1.91, 95% CI 1.69, 2.17). We analyze these data to quantify the extent and type of iatrogenic harm in the specialty, and make suggestions on the way forward. CONCLUSION AND LEVEL OF EVIDENCE: Despite the limitations of such analyses, it is clear that there are many proven interventions which can improve patient safety and need to be implemented. Avoidable errors must be prevented, lest we be accused of contravening our fundamental duty of primum non nocere. This is a level III evidence-based study.
    Full-text · Article · Mar 2013 · Drug, Healthcare and Patient Safety
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    • "Because of reporting bias, counting types of incidents, failures, problems and causes does not provide a valid picture of the true distribution [13]. Nevertheless, a classification system can support the analysis of incidents, aid the discovery of trends (e.g. "
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    ABSTRACT: OBJECTIVE: Validation of a Danish patient safety incident classification adapted from the World Health Organizaton's International Classification for Patient Safety (ICPS-WHO). DESIGN: /st>Thirty-three hospital safety management experts classified 58 safety incident cases selected to represent all types and subtypes of the Danish adaptation of the ICPS (ICPS-DK).Outcome MeasuresTwo measures of inter-rater agreement: kappa and intra-class correlation (ICC). RESULTS: /st>An average number of incident types used per case per rater was 2.5. The mean ICC was 0.521 (range: 0.199-0.809) and the mean kappa was 0.513 (range: 0.193-0.804). Kappa and ICC showed high correlation (r = 0.99). An inverse correlation was found between the prevalence of type and inter-rater reliability. Results are discussed according to four factors known to determine the inter-rater agreement: skill and motivation of raters; clarity of case descriptions; clarity of the operational definitions of the types and the instructions guiding the coding process; adequacy of the underlying classification scheme. CONCLUSIONS: /st>The incident types of the ICPS-DK are adequate, exhaustive and well suited for classifying and structuring incident reports. With a mean kappa a little above 0.5 the inter-rater agreement of the classification system is considered 'fair' to 'good'. The wide variation in the inter-rater reliability and low reliability and poor discrimination among the highly prevalent incident types suggest that for these types, precisely defined incident sub-types may be preferred. This evaluation of the reliability and usability of WHO's ICPS should be useful for healthcare administrations that consider or are in the process of adapting the ICPS.
    Full-text · Article · Jan 2013 · International Journal for Quality in Health Care
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    • "An increased rate of reporting, whereas in itself could imply that the culture of patient safety is improving, on its own is of limited value. The NPSA had received 158 incidents in 2003 and now has over five million incidents reported to it [19,20]. Paradoxically, despite the large number of incident reports received by the NPSA, reporting systems have been shown to detect only about 6% of adverse events found by systematic review of records [21]. "
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    ABSTRACT: Orthopaedic surgery is a high-risk specialty in which errors will undoubtedly occur. Patient safety incidents can yield valuable information to generate solutions and prevent future cases of avoidable harm. The aim of this study was to understand the causative factors leading to all unnecessary deaths in orthopaedics and trauma surgery reported to the National Patient Safety Agency (NPSA) over a four-year period (2005-2009), using a qualitative approach. Reports made to the NPSA are categorised and stored in the database as free-text data. A search was undertaken to identify the cases of all-cause mortality in orthopaedic and trauma surgery, and the free-text elements were used for thematic analysis. Descriptive statistics were calculated based on the incidents reported. This included presenting the number of times categories of incidents had the same or similar response. Superordinate and subordinate categories were created. A total of 257 incident reports were analysed. Four main thematic categories emerged. These were: (1) stages of the surgical journey - 118/191 (62%) of deaths occurred in the post-operative phase; (2) causes of patient deaths - 32% were related to severe infections; (3) reported quality of medical interventions - 65% of patients experienced minimal or delayed treatment; (4) skills of healthcare professionals - 44% of deaths had a failure in non-technical skills. Most complications in orthopaedic surgery can be dealt with adequately, provided they are anticipated and that risk-reduction strategies are instituted. Surgeons take pride in the precision of operative techniques; perhaps it is time to enshrine the multimodal tools available to ensure safer patient care.
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