Anomalies
(difference from successful aviation system)
The original ambitions for incident reporting in healthcare were simple. Staff would identify and report problems and mishaps; patient safety risks would be investigated and addressed and the resulting lessons would be widely shared and implemented. Successful patient safety incident reporting systems would support system-wide learning.
Instead, incident reporting systems have focused on the quantity of incidents reported rather than the quality of investigation and improvement activities (see Table 1).
- Criteria for which incidents to report tend to be framed broadly —
any unintended or unexpected incidents that could have or did lead to harm
. - Increasing the number of reports seems to be a constant goal in many healthcare systems. A focus on quantity over quality leads to large numbers of reports with little new information. For instance, falls account for approximately one-fifth of incidents reported. Arguably, the incidence of common types of patient falls could be better recorded through other means, leaving incident reporting systems to focus on the most serious, unusual or unexpected events from which most can be learnt.
- Numbers or rates of reported incidents offer a particularly poor way of measuring safety performance. Yet, trends and charts of reporting rates remain commonly used organisational safety measures.
- There are continual calls to improve the quality of reported incident data. Incident reports do not need much detail. For any important event, the resulting in-depth investigation provides the level and quality of detail required.
| Key principles in other industries | Common practices in healthcare |
|---|---|
| Focus on reporting incidents that provide serious, specific or surprising insights into system safety | Encourage reporting of any and all incidents that may in some way relate to safety concerns |
| Avoid swamping the reporting system to ensure thorough review of all reported incidents | Celebrate large quantities of incident reports and aim for ever-increasing overall reporting rates |
| Use incident reports to identify and prioritise significant, new or emerging risks | Quantify, count and chart different categories of incident report to monitor performance trends |
| Harness the social processes of reporting to generate increased awareness and reporting of current risks | Aim to increase reporting rates to address perceived epidemiological or statistical biases in reported data |
| Expect reports to be inaccurate and incomplete; focus on investigation as the means of obtaining complete picture | Improve accuracy of incident reports through more comprehensive data collection processes |
| Apply pragmatic incident taxonomies that support basic analysis, improvement action and retrospective search | Expect incident taxonomies to accurately explain and map complex realities |
| Ensure incident reporting systems are managed and coordinated by an operationally independent group | Incidents reported to direct supervisors or other operational managers within organisation |
| Reporting constitutes one component of broad range of conversations and activities focused on safety and risk | Incident reporting represents the most visible safety activity for many organisations |
| Create regimes of mutual accountability for improvement and peer review of actions around incidents | Use reported incident data as an indicator to monitor organisational safety performance |
References
-
Macrae C.
The problem with
incident reporting
BMJ Qual Saf 2017;25:71-75.