Problems with incident reporting: reports lead rarely to recommendations
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CitationLiukka, Mari. Hupli, Markku. Turunen, Hannele. (2019). Problems with incident reporting: reports lead rarely to recommendations. Journal of clinical nursing, [Epub ahead of print 17 Jan 2019], 10.1111/jocn.14765.
Aim and objective
To analyse trends in incident reporting over the last 5 years and determine how many reports led to recommendations?
Patient safety incident reporting systems have been used in health care for years. However, they have a significant weakness in that reports often do not lead to any visible action.
The study is a retrospective register study. STROBE checklist was applied in the preparation of the paper.
Data were collected from a web‐based incident reporting database (HaiPro) for a social‐ and healthcare organisation in Finland, covering the period from 2011–2015.
In total, 16,019 incident reports were analysed. In 2.7% (n = 426) of all reports, there was written recommendation to develop action that such incidents would not happen again. Those reports were classified into seven categories: education, introduction and information, introduction to work, patient care, guidelines, instruments and IT programmes, and the physical environment.
Managers get major amount incident reports. There should be (a) a definition what kind of events should be reported, (b) a definition for how serious events managers have to make a recommendation and (c) control that recommendations are implemented.
Relevance to clinical practice
There is a need for more action to promote patient safety based on incident reports.