Accuracy of Harm Scores Entered Into an Event Reporting System

Abstract

This quality improvement project evaluated the accuracy of harm scores entered into an event reporting system by inpatient nursing staff at a National Cancer Institute-designated comprehensive cancer center. Nurses scored 10 safety scenarios using 2 versions of the Agency for Healthcare Research and Quality scale to determine interrater reliability. Results indicated inconsistency in the way nurses scored the scenarios, suggesting that the event reporting system may not accurately portray the severity of harm in patient safety events. Nurse executives can use this information to guide the development and implementation of incident reporting systems.

Patient Safety Narratives as a Key to Promoting Quality Measurement

“…The re-evaluation procedures identified 12% of 'patient fall' events from events that were originally labelled as 'miscellaneous', and in 'patient fall' category, 4% of 'un-witnessed' events that were labelled as 'others'. Other researchers reported poor to moderate inter-rater reliabilities by re-categorizing the events ( Figure 1) according to the harm scores defined in the Common Formats [7,8].…”

Embedding the clinician-researcher pharmacist in healthcare

“…345,347 The spectrum of reported events is limited, because most physicians do not utilise event reporting systems. 343,351 Our study reflected the evidence base that the medical profession was the lowest to report, accounting for 3% of the medicine incidents reported in the study period.…”

“…332,344,345 As system evaluation relies on risk reporting it is important to evaluate the incident severity that is assigned by the clinician as this dictates the level of review by the health care system.…”

“…193 A recent paper from the USA "indicated inconsistency in the way nurses scored the scenarios, suggesting that the event reporting system may not accurately portray the severity of harm in patient safety events." Page 218 375 Many medication errors can be prevented by introducing safe systems and safe medication practices. Most detection studies have concentrated on improving reporting rates as the answer.…”

“…343,344 Despite the limitations of non-mandated staff reporting, it is still recommended and encouraged internationally as the preferred method of capturing information on medicine incidents. 332,[343][344][345]351 Little research has been done to reflect on the accuracy of voluntary reporting in identifying clinical risk. Use of Incident Severity Rating (ISR) scores is common in Australian public hospitals.…”