Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

Ferroli, Paolo; Caldiroli, Dario; Acerbi, Francesco; Scholtze, Maurizio; Piro, A; Schiariti, Marco; Orena, Eleonora; Castiglione, Melina; Broggi, Morgan; Perin, Alessandro; DiMeco, Francesco

doi:10.3171/2012.9.focus12252

Cited by 20 publications

(20 citation statements)

References 22 publications

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“…CQC patient survey results are outcome factors commonly used to characterize institutions. [ 35 , 41 , 42 ] With respect to using CQC patient survey results there is potential for bias in relying on the patient’s perception of care. Patients may over-estimate safety within an institution as they are not necessarily aware of safety issues.…”

Section: Discussionmentioning

confidence: 99%

Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

et al. 2015

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BackgroundThe National Reporting and Learning System (NRLS) collects reports about patient safety incidents in England. Government regulators use NRLS data to assess the safety of hospitals. This study aims to examine whether annual hospital incident reporting rates can be used as a surrogate indicator of individual hospital safety. Secondly assesses which hospital characteristics are correlated with high incident reporting rates and whether a high reporting hospital is safer than those lower reporting hospitals. Finally, it assesses which health-care professionals report more incidents of patient harm, which report more near miss incidents and what hospital factors encourage reporting. These findings may suggest methods for increasing the utility of reporting systems.MethodsThis study used a mix methods approach for assessing NRLS data. The data were investigated using Pareto analysis and regression models to establish which patients are most vulnerable to reported harm. Hospital factors were correlated with institutional reporting rates over one year to examine what factors influenced reporting. Staff survey findings regarding hospital safety culture were correlated with reported rates of incidents causing harm; no harm and death to understand what barriers influence error disclosure.Findings5,879,954 incident reports were collected from acute hospitals over the decade. 70.3% of incidents produced no harm to the patient and 0.9% were judged by the reporter to have caused severe harm or death. Obstetrics and Gynaecology reported the most no harm events [OR 1.61(95%CI: 1.12 to 2.27), p<0.01] and pharmacy was the hospital location where most near-misses were captured [OR 3.03(95%CI: 2.04 to 4.55), p<0.01]. Clinicians were significantly more likely to report death than other staff [OR 3.04(95%CI: 2.43 to 3.80) p<0.01]. A higher ratio of clinicians to beds correlated with reduced rate of harm reported [RR = -1.78(95%Cl: -3.33 to -0.23), p = 0.03]. Litigation claims per bed were significantly negatively associated with incident reports. Patient satisfaction and mortality outcomes were not significantly associated with reporting rates. Staff survey responses revealed that keeping reports confidential, keeping staff informed about incidents and giving feedback on safety initiatives increased reporting rates [r = 0.26 (p<0.01), r = 0.17 (p = 0.04), r = 0.23 (p = 0.01), r = 0.20 (p = 0.02)].ConclusionThe NRLS is the largest patient safety reporting system in the world. This study did not demonstrate many hospital characteristics to significantly influence overall reporting rate. There were no association between size of hospital, number of staff, mortality outcomes or patient satisfaction outcomes and incident reporting rate. The study did show that hospitals where staff reported more incidents had reduced litigation claims and when clinician staffing is increased fewer incidents reporting patient harm are reported, whilst near misses remain the same. Certain specialties report more near misses than others, and doctors r...

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Section: Discussionmentioning

confidence: 99%

Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

et al. 2015

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“…There is very little information in the literature that reviews neurosurgical error in the format described by the RCA committees. Ferroli and his team in Italy have published one of the few reports that attempted to analyse neurosurgical error by applying an incident‐reporting model in the neurosurgical operating theatre using the expertise of an aviation system expert . They found that few studies were available to them regarding the implementation of an incident‐reporting system within a neurosurgical department.…”

Section: Discussionmentioning

confidence: 99%

Root cause analysis of critical events in neurosurgery, New South Wales

Perotti

Sheridan

2015

ANZ Journal of Surgery

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“…A research study suggested that in order for this aviation style reporting process to work effectively, all the people involved should be within the same institution. 5…”

Section: Aviation Mode Of Incident Reportingmentioning

confidence: 99%

Incident reporting in surgery: a review of the literature

Hossain

2015

Int Surg J

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There has been a worldwide recognition to report and learn from error in surgery. Adverse events if identified and reported can serve as learning points to prevent repetition. A number of schemes have emerged to report adverse events both nationally coordinated as well as independent voluntary reporting systems. It is envisaged incident reporting of the future will be a process whereby surgeons learn from adverse events from each other globally and collaborate to make healthcare safer.

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Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

Cited by 20 publications

References 22 publications

Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

Can Patient Safety Incident Reports Be Used to Compare Hospital Safety? Results from a Quantitative Analysis of the English National Reporting and Learning System Data

Root cause analysis of critical events in neurosurgery, New South Wales

Incident reporting in surgery: a review of the literature

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