Integrating Incident Data from Five Reporting Systems to Assess Patient Safety: Making Sense of the Elephant

Levtzion‐Korach, Osnat; Frankel, Allan; Alcalai, Hanna; Keohane, Carol A.; Orav, John; Graydon-Baker, Erin; Barnes, Janet Nally; Gordon, Kathleen; Puopolo, Anne Louise; Tomov, Elena Ivanova; Sato, Luke; Bates, David W.

doi:10.1016/s1553-7250(10)36059-4

Cited by 116 publications

(115 citation statements)

References 28 publications

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“…Healthcare organizations view diagnostic error as the responsibility of its physician staff, who in turn believe that they are practicing at exceptionally high levels [54]. As evidence of this dilemma, physicians typically fail to participate in incident reporting systems [55], underuse decision support resources [56], and are generally unable to recognize cases where their clinical judgment was incorrect [57].…”

Section: Discussionmentioning

confidence: 99%

The new diagnostic team

et al. 2017

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Abstract:The National Academy of Medicine (NAM) in the recently issued report Improving Diagnosis in Health Care outlined eight major recommendations to improve the quality and safety of diagnosis. The #1 recommendation was to improve teamwork in the diagnostic process. This is a major departure from the classical approach, where the physician is solely responsible for diagnosis. In the new, patient-centric vision, the core team encompasses the patient, the physician and the associated nursing staff, with each playing an active role in the process. The expanded diagnostic team includes pathologists, radiologists, allied health professionals, medical librarians, and others. We review the roles that each of these team members will need to assume, and suggest "first steps" that each new team member can take to achieve this new dynamic.

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Section: Discussionmentioning

confidence: 99%

The new diagnostic team

et al. 2017

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“…theatre, ICU, patient falls, nursing care, and medication vide supra, CIRS and related voluntary reporting systems are predominantly used by nursery staff whereas it is rarely used by other clinical staff members, in particular physicians [7,18,26,27]. In one case, it was found that physicians reported adverse events mostly via the clinical risk management, while nursing staff used more often CIRS settings [26]. This observation may reflect the reluctance of clinical professionals to internalize the necessity of an error culture [28].…”

Section: Who Has Reported?mentioning

confidence: 99%

“…Several issues of further importance were found: (i) technical measures derived from incident reports may lead to new error resources [50]; (ii) the probable importance of national incident-reporting systems relevant to anaesthesia [31]; (iii) an inflationary push of CI-reporting systems without a sound comprehension or planning (see Ramanujam et al [30] for an example in medication); (iv) ineffectiveness in dealing with CI reports [4]; (v) the relationship between CIRS and related reporting systems with organizational quality management [52]; (vi) complementary approaches of CIRS [5,6,8,16,26]; and (vii) the dispute on the relationship between incident report frequency and patient safety [8,12,15,17,18,20,21,25,53].…”

Section: Further Cognitionmentioning

confidence: 99%

Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety

Petschnig

Haslinger-Baumann

2017

Saf Health

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Background: The complexity of health care systems, the development of clinical approaches, and both scientific and technological advancements give rise to new requirements in clinical risk management. An expedient risk management is expected to deal with as many risks as possible to ensure patient safety. A prerequisite for a clinical risk management is a well-functioning error-reporting culture in health care organizations. The present study analysed the relationship between the Critical Incident Reporting System (CIRS) and patient safety. In particular, the aim of this work is to evaluate whether data from available sources provide sufficient evidence for the utility of CIRS and to derive recommendations for both theorists and practitioners. On paper, CIRS is expected to be useful in clinical settings because it allows the identification of weak spots, hazards, and critical situations such as 'near misses'. However, neither a general CIRS database based on clinical reports exists nor a universal CIRS policy or CIRS direction has been established so far, which can be attributed to the inhomogeneity of the literature and the variability of approaches. Therefore, ordering and analysis of clinical reports are highly desirable. Methods: First, inclusion criteria, exclusion criteria, and keywords were defined to collect studies, reviews, and other sources on CIRS from official databases. After the collection of appropriate articles, a description of the individual data is given. Then, data are classified into different sections based on their respective central statements, and a brief description is given. Finally, the reports are analysed in order to detect patterns and differences. Results: There is a close correlation between the establishment of CIRS in a health care organization and patient safety, although a quantitative relationship between reporting systems and safety is still unproven. CIRS allows the identification and implementation of appropriate actions and strategies toward patient safety. Several prerequisites were identified: top management commitment, transparency, training, anonymity, incentives, and an open error-reporting culture. Personnel have an important impact on the reduction of risk and on the development of safety. The leadership should accept the implementation of a "no blame" error and feedback culture and the security of an absolutely anonymous reporting system. The position of a risk or safety manager is highly recommended. Conclusion: As immediate recommendations, health care organizations are encouraged to adopt CIRS. On the other hand, several research topics were identified, such as the quantitative relationship between CIRS and safety or the development of reliable incident-reporting indices and the ways on how to deal with them. Intensified empirically based research may help in answering open questions concerning CIRS.

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“…In a series of studies, patients endorsed their willingness to perform error-prevention activities such as asking questions about medications and medical care, helping to mark a surgical site, and reporting an error to the medical staff. 4 Building on the concept of the vigilant partner, researchers have shown that patients are able to recognize medical errors, some of which are not otherwise identified by existing health care monitoring systems (Levtzion-Korach, Frankel, Alcalai, et al, 2010), and are willing and able to report this information reliably. 5 As demonstrated in the United Kingdom, these reports can strengthen the ability of health care organizations to detect systemic problems in care.…”

Section: Value Of Patient Reportingmentioning

confidence: 99%