Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The STEP trials

A round-up of the STEP phase 3 clinical trials evaluating semaglutide for weight loss in people with overweight or obesity.
ADVANCED SEARCH
Log in
Top
Archives of Public Health
Published in: Archives of Public Health 1/2016

Open Access 01-12-2016 | Research

Incident reporting systems: a comparative study of two hospital divisions

Authors: Tanya Hewitt, Samia Chreim, Alan Forster

Published in: Archives of Public Health | Issue 1/2016

Login to get access

Abstract

Background

Previous studies of incident reporting in health care organizations have largely focused on single cases, and have usually attended to earlier stages of reporting. This is a comparative case study of two hospital divisions’ use of an incident reporting system, and considers the different stages in the process and the factors that help shape the process.

Method

The data was comprised of 85 semi-structured interviews of health care practitioners in general internal medicine, obstetrics and neonatology; thematic analysis of the transcribed interviews was undertaken. Inductive and deductive themes are reported. This work is part of a larger qualitative study found elsewhere in the literature.

Results

The findings showed that there were major differences between the two divisions in terms of: a) what comprised a typical report (outcome based vs communication and near-miss based); b) how the reports were investigated (individual manager vs interdisciplinary team); c) learning from reporting (interventions having ambiguous linkages to the reporting system vs interventions having clear linkages to reported incidents); and d) feedback (limited feedback vs multiple feedback).

Conclusions

The differences between the two divisions can be explained in terms of: a) the influence of litigation on practice, b) the availability or lack of interprofessional training, and c) the introduction of the reporting system (top-down vs bottom-up approach). A model based on the findings portraying the influences on incident reporting and learning is provided. Implications for practice are addressed.
Literature
1.
Kohn LT, Corrigan JM, Donaldson MS. To Err is Human: Building a Safer Health System. Washington D.C.: National Academy Press; 1999.
2.
Chief Medical Officer. An Organization with a Memory : Report of an expert group on learning from adverse events in the NHS. London: National Health Service; 2000.
3.
Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox J, et al. The Canadian Adverse Events Study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170(11):1678–85.CrossRef
4.
Donaldson SLJ. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems - From Information to Action. Geneva: WHO Document Production Services; 2005.
5.
Swartz T. Do you know your hospital ? Event reporting helps quality improvement and patient safety efforts. Patient Safety Monitor J. 2011;12:7–10.
6.
Osmon S, Harris CB, Dunagan WC, Prentice D, Fraser VJ, Kollef MH. Reporting of medical errors: An intensive care unit experience. Crit Care Med. 2004;32(3):727–33.CrossRefPubMed
7.
Morag I, Gopher D, Spillinger A, Auerbach-Shpak Y, Laufer N, Lavy Y, et al. Human Factors-Focused Reporting System for Improving Care Quality and Safety in Hospital Wards. Human Factors: The Journal of the Human Factors and Ergonomics Society. 2012;54(2):195–213.CrossRef
8.
Blais R, Bruno D, Bartlett G, Tamblyn R. Can We Use Incident Reports to Detect Hospital Adverse Events ? J Patient Saf. 2008;4(1):9–12.
9.
Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400–2.CrossRefPubMed
10.
Shojania KG. The Elephant of Patient Safety: What You See Depends on How You Look. The Joint Commission Journal on Quality and Patient Safety. 2010;36(9):399–401.CrossRefPubMed
11.
D. R. Levinson, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm,” Report No. OEI-06-09-00091 Office of Inspector General, Department of Health and Human Services, Washington D.C., 2012
12.
Pronovost PJ, Thompson DA, Holzmueller CG, Lubomski LH, Dorman T, Dickman F, et al. Toward learning from patient safety reporting systems. J Crit Care. 2006;21(4):305–15.CrossRefPubMed
13.
Hewitt TA, Chreim S, Forster AJ. Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses : Understanding Frames Underlying Self- and Peer-Reporting Practices. J Patient Saf. 2014;00(00):1–9.CrossRef
14.
Haller G, Courvoisier DS, Anderson H, Myles PS. Clinical factors associated with the non-utilization of an anaesthesia incident reporting system. Br J Anaesth. 2011;107(2):171–9.CrossRefPubMed
15.
Anderson JE, Kodate N, Walters R, Dodds A. Can incident reporting improve safety? Healthcare practitioners’ views of the effectiveness of incident reporting. International J Qual Health Care. 2013;25(2):141–50.CrossRef
16.
Miles MB, Huberman AM. Qualitative data analysis. 2nd ed. Thousand Oaks: Sage; 1994.
17.
Øvretveit JC. The contribution of new social science research to patient safety. Soc Sci Med. 2009;69(12):1780–3.CrossRefPubMed
18.
Hor S, Iedema R, Williams K, White L, Kennedy P, Day AS. Multiple accountabilities in incident reporting and management. Qual Health Res. 2010;20(8):1091–100.CrossRefPubMed
19.
Waring J, Currie G. Managing Expert Knowledge: Organizational Challenges and Managerial Futures for the UK Medical Profession. Organization Studies. 2009;30(7):755–78.CrossRef
20.
Hewitt TA. Incident Reporting Systems – The Hidden Story. J Safety Reliability Soc. 2013;33(2):13–28.CrossRef
21.
Tighe CM, Woloshynowych M, Brown R, Wears RL, Vincent CA. Incident reporting in one UK accident and emergency department. Accid Emerg Nurs. 2006;14(1):27–37.CrossRefPubMed
22.
Cunningham TR, Geller ES. A Comprehensive Approach to Identifying Intervention Targets for Patient-Safety Improvement in a Hospital Setting. J Org Behav Manag. 2012;32(3):194–220.
23.
Noble D, Pronovost PJ. Underreporting of Patient Safety Incidents Reduces Health Care’s Ability to Quantify and Accurately Measure Harm Reduction. J Patient Saf. 2010;6(4):247–50.CrossRefPubMed
24.
Kreckler S, Catchpole K, McCulloch P, Handa A. Factors influencing incident reporting in surgical care. Qual Saf Health Care. 2009;18(2):116–20.CrossRefPubMed
25.
Brubacher JR, Hunte GS, Hamilton L, Taylor A. Barriers to and incentives for safety event reporting in emergency departments. Healthcare Quarterly (Toronto, Ont). 2011;14(3):57–65.CrossRef
26.
Waring J. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med. 2005;60(9):1927–35.CrossRefPubMed
27.
Logio LS, Ramanujam R. Medical trainees’ formal and informal incident reporting across a five-hospital academic medical center. Jt Comm J Qual Patient Saf. 2010;36(1):36–42.CrossRefPubMed
28.
Moore L, McAuliffe E. To report or not to report? Why some nurses are reluctant to whistleblow. Clinical Governance: An International Journal. 2012;17(4):332–42.CrossRef
29.
Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. Journal of public health research. 2013;2(3):154–9.CrossRef
30.
Wachter RM. Patient safety at ten: Unmistakable progress, troubling gaps. Health Aff. 2010;29(1):165–73.CrossRef
31.
32.
Bush K. Fixing the System: Practical Examples of Patient Safety and Learning From Adverse Events in Respiratory Therapy. Canadian Journal of Respiratory Therapy. 2010;46(4):6–12.
33.
34.
Wallace LM, Spurgeon P, Benn J, Koutantji M, Vincent CA. Improving patient safety incident reporting systems by focusing upon feedback - lessons from English and Welsh trusts. Health services management research : an official journal of the Association of University Programs in Health Administration/HSMC, AUPHA. 2009;22(3):129–35.CrossRef
35.
Benn J, Arnold G, Wei I, Riley C, Aleva F. Using quality indicators in anaesthesia: Feeding back data to improve care. Br J Anaesth. 2012;109(1):80–91.CrossRefPubMed
36.
Boike JR, Bortman JS, Radosta JM, Turner CL, Anderson-Shaw L, Centomani NM, et al. Patient safety event reporting expectation: does it influence residents’ attitudes and reporting behaviors? J Patient Saf. 2013;9(2):59–67.CrossRefPubMed
37.
Lubberding S, Zwaan L, Timmermans DRM, Wagner C. The nature and causes of unintended events reported at 10 internal medicine departments. J Patient Saf. 2011;7(4):224–31.CrossRefPubMed
38.
Snijders C, Kollen BJ, van Lingen RA, Fetter WPF, Molendijk H. Which aspects of safety culture predict incident reporting behavior in neonatal intensive care units? A multilevel analysis. Crit Care Med. 2009;37(1):61–7.CrossRefPubMed
39.
Waters NF, Hall WA, Brown H, Espezel H, Palmer L. Perceptions of Canadian labour and delivery nurses about incident reporting: a qualitative descriptive focus group study. Int J Nurs Stud. 2012;49(7):811–21.CrossRefPubMed
40.
Ahluwalia J, Marriott L. Critical incident reporting systems. Semin Fetal Neonatal Med. 2005;10(1):31–7.CrossRefPubMed
41.
Pope C, Mays N. Reaching the parts other methods cannot reach: an introduction to qualitative methods in health and health services research. BMJ (Clinical research ed). 1995;311(6996):42–5.CrossRef
42.
Eisenhardt KM. Building theories from case study research. Acad Manage Rev. 1989;14:532–50.
43.
Yin RK. Designing case studies: Identifying your case(s) and establishing the logic of your case study. 4th ed. Thousand Oaks: Sage; 2003. p. 25–66.
44.
Guba EG, Lincoln YS. Establishing trustworthiness,” in Naturalistic inquiry. 2nd ed. Beverley Hills: Sage; 1985. p. 289–331.
45.
Dixon-Woods M, Leslie M, Tarrant C, Bion J. Explaining Matching Michigan: an ethnographic study of a patient safety program. Implementation science. 2013;8(no. 1):70.CrossRefPubMedPubMedCentral
46.
Bosk CL, Dixon-Woods M, Goeschel CA, Pronovost PJ. Reality check for checklists. The Lancet. 2009;374(9688):444–5.CrossRef
47.
Dixon-Woods M, Bosk CL, Aveling L, Goeschel CA, Pronovost PJ. Explaining Michigan: Developing an Ex Post Theory of a Quality Improvement Program. Milbank Quarterly. 2011;89(2):167–205.CrossRefPubMedPubMedCentral
48.
Nuckols TK, Bell DS, Paddock SM, Hilborne LH. Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals. Jt Comm J Qual Patient Saf. 2009;35(3):139–45.CrossRefPubMed
49.
Summers AE. Continuous improvement and existing safety systems. Journal of Loss Prevention in the Process Industries. 2009;22:685–8.CrossRef
50.
Sanne JM. Incident reporting or storytelling? Competing schemes in a safety-critical and hazardous work setting. Safety Science. 2008;46(8):1205–22.CrossRef
51.
Benn J, Koutantji M, Wallace LM, Spurgeon P, Rejman M, Healey A, et al. Feedback from incident reporting: information and action to improve patient safety. Quality and Safety in Health Care. 2009;18(1):11–21.CrossRefPubMed
52.
53.
Leape LL. Who’s to Blame? The Joint Commission Journal on Quality and Patient Safety. 2010;36(4):150–1.CrossRefPubMed
54.
Florea A, Caughey SS, Westland J, Berckmans M, Kennelly C, Beach C, et al. The Ottawa Hospital Quality Incident Notification System for Capturing Adverse Events in Obstetrics. Journal of obstetrics and gynecology Canada. 2010;32(7):657–62.CrossRef
55.
56.
57.
Reay T, Chreim S, Golden-Biddle K, Goodrick E, Williams BEB, Casebeer A, et al. Transforming New Ideas into Practice: An Activity Based Perspective on the Institutionalization of Practices. Journal of Management Studies. 2013;50(6):963–90.CrossRef
58.
Milne JK, Walker DE, Vlahaki D. Reflections on the Canadian MORE(OB) obstetrical risk management programme. Best Pract Res Clin Obstet Gynaecol. 2013;27(4):563–9.CrossRefPubMed
59.
P. G. Shekelle, R. M. Wachter, P. J. Pronovost, K. Schoelles, K. M. McDonald, S. M. Dy, K. G. Shojania, J. Reston, Z. Berger, B. Johnsen, J. Larkin, S. Lucas, K. Martinez, A. Motala, S. Newberry, M. Noble, E. Pfoh, S. Ranji, S. Rennke, E. Schmidt, R. Shanman, and B. Sulli, “Making Health Care Safer II : An Updated Critical Analysis of the Evidence for Patient Safety Practices,” Rockville, MD, 2013 Available: http://​www.​ahrq.​gov/​research/​findings/​evidence-based-reports/​ptsafetyuptp.​html. Accessed 09 June 2016.
60.
Connor M, Ponte PR, Conway J. Multidisciplinary approaches to reducing error and risk in a patient care setting. Crit Care Nurs Clin North Am. 2002;14(no. 4):359–67. viii.CrossRefPubMed
61.
Weaver SJ, Lubomksi L, Wilson R, Pfoh E, Martinez K, Dy SM. Annals of Internal Medicine Supplement Promoting a Culture of Safety as a Patient Safety Strategy. Ann Intern Med. 2013;158(5):369–74.CrossRefPubMedPubMedCentral
62.
Siassakos D, Fox R, Bristowe K, Angouri J, Hambly H, Robson L, et al. What makes maternity teams effective and safe? Lessons from a series of research on teamwork, leadership and team training. Acta Obstet Gynecol Scand. 2013;92(11):1239–43.CrossRefPubMed
63.
Cornthwaite K, Edwards S, Siassakos D. Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Pract Res Clin Obstet Gynaecol. 2013;27(4):571–81.CrossRefPubMed
64.
Pronovost PJ, Holzmueller CG, Ennen CS, Fox HE. Overview of progress in patient safety. Am J Obstet Gynecol. 2011;204(1):5–10.CrossRefPubMed
65.
Mann S, Marcus R, Sachs B. Lessons from the Cockpit: how team training can reduce errors on L & D,” Comtemporary OB/GYN. 2006. p. 34–45.
66.
Lewis R, Strachan A, Smith MM. Is high fidelity simulation the most effective method for the development of non-technical skills in nursing? A review of the current evidence. The open nursing journal. 2012;6:82–9.CrossRefPubMedPubMedCentral
67.
Daniels K, Auguste T. Moving forward in patient safety: multidisciplinary team training. Semin Perinatol. 2013;37(3):146–50.CrossRefPubMed
68.
Wears RL, Karsh B-T. Thick versus thin: description versus classification in learning from case reviews. Ann Emerg Med. 2008;51(3):262–4.CrossRefPubMed
69.
70.
Le Coze JC. What have we learned about learning from accidents? Post-disasters reflections. Safety Science. 2013;51(1):441–53.CrossRef
71.
Stoop J, Dekker SWA. Are safety investigations pro-active? Safety Science. 2012;50(6):1422–30.CrossRef
72.
Hollnagel E. " Is safety a subject for science?” Safety Science. 2014;67(8):21-24.
73.
Lundberg J, Rollenhagen C, Hollnagel E. What-You-Look-For-Is-What-You-Find – The consequences of underlying accident models in eight accident investigation manuals. Safety Science. 2009;47(10):1297–311.CrossRef
74.
Dekker SWA, Pruchnicki S. Drifting into failure: theorising the dynamics of disaster incubation. Theoretical Issues in Ergonomics Science. 2013;15(6):534–44.CrossRef
75.
Dekker SWA. Doctors Are More Dangerous Than Gun Owners: A Rejoinder to Error Counting. Human Factors: The Journal of the Human Factors and Ergonomics Society. 2007;49(2):177–84.CrossRef
76.
77.
Woodier N. Moving from Safety I to Safety II, but what about the media? BMJ Quality & Safety. 2015;24(2):178–8.CrossRef
78.
Hollnagel E. Safety-I and Safety-II The Past and Future of Safety Management. Burlington: Ashgate Publishing Ltd; 2014.
79.
Dekker SWA. Book review - Safety I and Safety II, Hollnagel Erik Ashgate publishing. Journal of Contingencies and Crisis Management. 2010;5(1):87–8.
80.
Nembhard IM, Tucker AL. Deliberate Learning to Improve Performance in Dynamic Service Settings: Evidence from Hospital Intensive Care Units. Organization Science. 2010;22(4):907–22.CrossRef
81.
Arriaga AF, Gawande AA, Raemer DB, Jones DB, Smink DS, Weinstock P, et al. Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams. Ann Surg. 2014;259(3):403–10.CrossRefPubMed
82.
Bohmer RMJ. The Four Habits of High-Value Health Care Orgnaizations. N Engl J Med. 2011;365(22):2045–7.CrossRefPubMed
83.
Tucker AL, Edmondson AC. Why hospitals don’t learn from failures: Organizational and psychological dynamics that inhibit system change. Calif Manage Rev. 2003;45(2):55–72.CrossRef
84.
Pronovost PJ, Marsteller JA, Goeschel CA. Preventing bloodstream infections: A measurable national success story in quality improvement. Health Aff. 2011;30(4):628–34.CrossRef
85.
Leveson NG. Engineering a Safer World. Cambridge: MIT Press; 2011.
86.
L. M. Wallace, “Feedback from reporting patient safety incidents – are NHS trusts learning lessons?” J Health Serv Res Policy. 2010 Jan;15 Suppl 1:75-8
Metadata
Title
Incident reporting systems: a comparative study of two hospital divisions
Authors
Tanya Hewitt
Samia Chreim
Alan Forster
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Archives of Public Health / Issue 1/2016
Electronic ISSN: 2049-3258
DOI
https://doi.org/10.1186/s13690-016-0146-8

Other articles of this Issue 1/2016

Archives of Public Health 1/2016 Go to the issue

Research

Association between pregnancy exposure to air pollution and birth weight in selected areas of Norway

Study protocol

Phase III evaluation of the insecticidal efficacy and durability of a deltamethrin-treated polypropylene long-lasting net LifeNet®, in comparison with long-lasting nets made from polyester and polyethylene: study protocol

Research

Social, economic and environmental risk factors for acute lower respiratory infections among children under five years of age in Rwanda

LETTER TO THE EDITOR

Persistent misunderstandings about evidence-based (sorry: informed!) policy-making

Systematic review

Estimate of adolescent alcohol use in China: a meta-analysis

Research

Accounting for multimorbidity can affect the estimation of the Burden of Disease: a comparison of approaches