Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems.
Limitations of IRS
- can't be used to measure safety (error rates)
- can't be used to compare organizations
- can't be used to measure changes over time
- generate too many reports
- often don't generate in-depth analyses or result in strong interventions to reduce risk
- are associated with costs
Advantages of IRS
- can be used to identify local system hazards
- can be used to aggregate experiences for uncommon conditions
- can be used to share lessons within and across organizations
- can be used to increase patient safety culture
Strategies to maximize IRS value
- make reporting easier
- make reporting meaningful to the reporter
- make the measure of success system changes, rather than events reported
- prioritize which events to report and investigate, report and investigate them well
- convene with diverse stakeholders to enhance the value of IRS
References
- Pham JC, Girard T, Pronovost PJ. What to do with healthcare Incident Reporting Systems {review} Journal of Public Heatlh Research 2013; 2:e27 pp.154-159