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Incident reporting: A key to improving patient safety

Patient Safety Quality Monthly, February 14, 2008

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Reducing medical errors has become a prime focus of healthcare organizations and external agencies (e.g., IHI, Leapfrog, NCQA) since the Institute of Medicine report To Err Is Human: Building a Safer Health System, which stated that "at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented."

Healthcare consumers expect error-free performance from those who care for them. But, as we know, errors occur. Although most errors are unintended, devastating outcomes can result. Reducing the incidence of medical errors requires gathering key information, trending outcomes, identifying common causes and apparent causes, and designing quality initiatives to prevent future errors.

Learning from actual events - whether or not an untoward outcome occurs - and near-miss events provides valuable information for improving patient safety and reducing hospital, physician, and staff liability exposure.

It is important to note that only a fraction of incidents and near misses are reported, which reduces the access to available systems safety information. To encourage reporting, facilities should:
 Put a leadership-driven focus on patient safety
 Implement a simple, easy-to-use reporting system
 Create a nonpunitive system
 Use data analysis tools
 Solicit staff and physician feedback on trends, related quality initiatives, and improvement results
 Use process and outcome analysis methods (root cause analysis, failure modes and effects analysis)

Future issues will focus on utilizing the techniques listed above to improve both the rate and quality of incident reporting and data analysis methods.

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