Ten years of online incident reporting and learning using CPiRLS: implications for improved patient safety.

Abstract

Background Safety Incident (SI) reporting and learning via incident reporting systems (IRS) is used to identify areas for patient safety improvement. The Chiropractic Patient Incident Reporting and Learning System (CPiRLS) was launched in 2009 and is currently available to all UK chiropractors and members of the European Chiropractors Union (ECU). The primary aim was to analyse the SIs submitted to CPiRLS over a 10-year period to identify key areas for patient safety improvement. Method All SIs on CPiRLS were extracted and analysed over a 10-year period (April 2009 to March 2019). Frequency statistics were used to describe 1) the level of SI reporting and learning by the chiropractic profession 2) the nature of the reported SIs including levels of patient harm. Key areas for patient safety improvement were identified following review of the database and consideration by an expert panel. Results A total of 268 SIs were recorded on the database over the 10-year period, of those, 85% originated from the UK. Evidence of learning was documented in 143 (53.4%) SIs. The largest subcategory of SIs related to post-treatment distress or pain, n = 71 (26.5%). Twenty-nine (10.8%) of all SIs involved a (potential) trip or fall with an additional eight SIs relating to syncope. A total of 26 (9.7%) SIs represented some type of rib distress or pain with 14 suggesting a rib fracture was likely to have occurred. Twenty-two (8.2%) SIs related to (potentially) missing a potential serious underlying pathology. Fourteen (5.2%) SIs involved disruption in the continuity of care. Six key areas of patient safety improvement were identified following review of the data and consideration of the expert panel. Conclusion Under-reporting of SIs is apparent on CPiRLS, however, an upward trend was identified over the 10-year period. Several key areas for patient safety improvement have been identified that need to be disseminated to the chiropractic profession including through the development of safer practice notices. Improved reporting practice needs to be facilitated to improve the value and validity of reporting data. CPiRLS is important in identifying key areas for patient safety improvement and should be reviewed periodically.