This was an interesting little study that evaluated the performance of a routine incident reporting system in identifying, and more importantly missing, patient safety incidents.
Data was compared between patient case notes and via analysis of the incident report data for the same patients; 1006 hospital admissions were evaluated.
Results
Of the 1006 admissions, 324 patient safety incidents were identified.
Interestingly, the incident reporting system identified just 17% of the total number of patient safety incidents compared to patient safety notes which identified 94% of events.
110 admissions resulted in patient harm, all of which were identified in patient notes compared to just 5% by the incident reporting system.
All of the patient safety incidents missed by case note review were minor in nature whereas “130 (44.7%) incidents missed by the reporting system led to patient harm” (p2).
Based on this sample and setting, it’s concluded that the routine incident reporting system may be “poor at identifying patient safety incidents, particularly those resulting in harm” (p1).
They note that the routine reporting system at this large hospital “missed most patient safety incidents that were identified by case note review” and suggests that “the routine reporting system considerably under-reports the scale and severity of patient safety incidents” (p2).
Other data supports these findings, finding that reporting systems detected just 24% of all patient safety incidents and only 5% resulting in patient harm.
Reasons why formalised reporting systems underperform are varied, but include “lack of feedback; time constraints; fear of shame, blame, litigation, or professional censure; and unsatisfactory processes” (p3).
They note that these results don’t mean that reporting and learning systems aren’t (or at least, can’t be useful), but rather “estimates of the type and severity of incidents are likely to be biased” (p3).
In saying that, however, they argue “More importantly, perhaps, the value of these data locally as a component of safety programmes is questionable” (p3).
[** And most simply, I think, highlights the need for multiple streams of varied intel; e.g. requisite variety.]
Authors: Sari, A. B. A., Sheldon, T. A., Cracknell, A., & Turnbull, A. (2007). Bmj, 334(7584), 79.
Study link: https://doi.org/10.1136/bmj.39031.507153.AE
Link to the LinkedIn article: https://www.linkedin.com/pulse/sensitivity-routine-system-reporting-patient-safety-nhs-hutchinson
SafetyInsights.org 