What to do with healthcare Incident Reporting Systems

 https://doi.org/10.4081/jphr.2013.e27

Julius Cuong Pham
Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Thierry Girard
Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

Peter J. Pronovost
Department of Emergency Medicine, Department of Anesthesia and Critical Care Medicine, Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, United States.

ABSTRACT

Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems.

These limitations include: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don’t generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. IRS do offer significant value; their value is found in the following: i) IRS can be used to identify local system hazards; ii) IRS can be used to aggregate experiences for uncommon conditions; iii) IRS can be used to share lessons within and across organizations; iv) IRS can be used to increase patient safety culture.
Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, report and investigate them well; v) convene with diverse stakeholders to enhance the value of IRS.