Evaluation of the Contributions of an Electronic Web-based Reporting System

Levtzion‐Korach, Osnat; Alcalai, Hanna; Orav, E. John; Graydon-Baker, Erin; Keohane, Carol A.; Bates, David W.; Frankel, Allan

doi:10.1097/pts.0b013e318198dc8d

Cited by 28 publications

(24 citation statements)

References 17 publications

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“…While similar studies have reported difficulty in enrolling physicians, including surgeons, this study demonstrates that physicians were willing participate in proactive reporting systems. 37, 38 The fact that the web-based debriefing successfully solicited reports from nursing staff, physician extenders (e.g., physician assistants), technicians, physicians (e.g., anesthesiologists, surgeons), residents and students is suggestive that this active, web-based tool is successfully integrated into the workflow and fewer barriers for participation exist than the traditional incident reporting system.…”

Section: Discussionmentioning

confidence: 99%

Detection of medical errors in kidney transplantation: A pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

McElroy

Daud

Lapin

et al. 2014

Surgery

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Background Rates of medical errors and adverse events remain high for kidney transplant patients, who are particularly vulnerable due to the complexity of their disease and the kidney transplant procedure. Although institutional incident reporting systems are utilized in hospitals around the country, they often fail to capture a substantial proportion of medical errors. The goal of this study was to assess the ability of a proactive, web-based clinician safety debriefing to augment the information about medical errors and adverse events obtained via traditional incident reporting systems. Methods Debriefings were sent to all individuals listed on operating room personnel reports for kidney transplantation surgeries between April 2010 and April 2011 and incident reports were collected for the same time period. The World Health Organization International Classification for Patient Safety was used to classify all issues reported. Results A total of 270 debriefings reported 334 patient safety issues (179 safety incidents, 155 contributing factors), and 57 incident reports reported 92 patient safety issues (56 safety incidents, 36 contributing factors). Compared to incident reports, more attending physicians completed the debriefings (32.0 vs. 3.5%). Discussion The use of a proactive, web-based debriefing to augment an incident reporting system in assessing safety risks in kidney transplantation demonstrated increased information, more perspectives of a single safety issue, and increased breadth of participants.

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Section: Discussionmentioning

confidence: 99%

Detection of medical errors in kidney transplantation: A pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

McElroy

Daud

Lapin

et al. 2014

Surgery

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“…These barriers include time constraints, arduous forms, lack of understanding of the incident system, lack of feedback and action following incident reporting and others (Evans et al., ; Kingston et al., ; Schectman & Plews‐Ogan, ; Waring, ). Electronic reporting systems have been increasingly implemented in healthcare in order to counter these barriers with benefits, including accessibility, ease of use, viewing of reports, as well as a general increased efficiency of the feedback loop (Levtzion‐Korach et al., ).…”

Section: Discussionmentioning

confidence: 99%

Completing the Audit Cycle: The Impact of an Electronic Reporting System on the Feedback Loop in Surgical Specialties

Mandavia¹,

Yassin²,

Dhar³

et al. 2013

Journal for Healthcare Quality

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“…As indicated by recent studies, a well-designed, integrated and carefully implemented electronic reporting system can have several advantages including accessibility, increased accuracy, elimination of illegible forms, ease of use and automated reporting [15,18,28,58]. Use of electronic artefacts based on standard computerised spreadsheet formats, supported by well structured dropdown selection functions and self populating fields may reduce the report creation time at the sites, mitigate information storage issues and facilitate timely collection of data by the headquarters [26,59,60].…”

Section: Discussionmentioning

confidence: 99%

“…Most RACFs have paper forms to report medication incidents consisting of mostly narrative free text fields to document the details of the incident [25-27]. This information is then analysed to identify root causes and initiate corrective actions to address incidents [28]. …”

Section: Introductionmentioning

confidence: 99%

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

2012

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BackgroundMedication incident reporting (MIR) is a key safety critical care process in residential aged care facilities (RACFs). Retrospective studies of medication incident reports in aged care have identified the inability of existing MIR processes to generate information that can be used to enhance residents’ safety. However, there is little existing research that investigates the limitations of the existing information exchange process that underpins MIR, despite the considerable resources that RACFs’ devote to the MIR process. The aim of this study was to undertake an in-depth exploration of the information exchange process involved in MIR and identify factors that inhibit the collection of meaningful information in RACFs.MethodsThe study was undertaken in three RACFs (part of a large non-profit organisation) in NSW, Australia. A total of 23 semi-structured interviews and 62 hours of observation sessions were conducted between May to July 2011. The qualitative data was iteratively analysed using a grounded theory approach.ResultsThe findings highlight significant gaps in the design of the MIR artefacts as well as information exchange issues in MIR process execution. Study results emphasized the need to: a) design MIR artefacts that facilitate identification of the root causes of medication incidents, b) integrate the MIR process within existing information systems to overcome key gaps in information exchange execution, and c) support exchange of information that can facilitate a multi-disciplinary approach to medication incident management in RACFs.ConclusionsThis study highlights the advantages of viewing MIR process holistically rather than as segregated tasks, as a means to identify gaps in information exchange that need to be addressed in practice to improve safety critical processes.

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Evaluation of the Contributions of an Electronic Web-based Reporting System

Abstract: This application effectively captured incidents, actions, and follow-up. Ease of data manipulation facilitated descriptive statistical analysis, and the ability to use branching algorithms may have helped in decision making about actions and follow-up.

Cited by 28 publications

References 17 publications

Detection of medical errors in kidney transplantation: A pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

Detection of medical errors in kidney transplantation: A pilot study comparing proactive clinician debriefings to a hospital-wide incident reporting system

Completing the Audit Cycle: The Impact of an Electronic Reporting System on the Feedback Loop in Surgical Specialties

Medication incident reporting in residential aged care facilities: Limitations and risks to residents’ safety

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