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• Making sense of the story - the true value of incident reporting
  Tara J Lamont
  Published on: 13 May 2016
• Incident Reporting - Let's Decentralise
  Merilyn A. Rees
  Published on: 13 May 2016

• Published on: 13 May 2016

  Making sense of the story - the true value of incident reporting

  • Tara J Lamont, Deputy Director

  I was interested to read the thoughtful article by Imogen Mitchell and colleagues, echoing longstanding criticisms by Kaveh Shojania, Charles Vincent and others on the low value of high volume incident reporting. There is little learning from categorical data, repeated many times, around falls or minor medication errors. However, there was a time at the National Patient Safety Agency, where we experimented with a multi...

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  I was interested to read the thoughtful article by Imogen Mitchell and colleagues, echoing longstanding criticisms by Kaveh Shojania, Charles Vincent and others on the low value of high volume incident reporting. There is little learning from categorical data, repeated many times, around falls or minor medication errors. However, there was a time at the National Patient Safety Agency, where we experimented with a multidisciplinary meeting to make sense of reports, screened by skilled clinical reviewers. We concentrated on the freetext - the `story' of the incident. These weekly meetings became a dynamic and illuminating discussion of problem and solutions, with fiercely contested accounts from differing perspectives (surgeon, theatre nurse, GP, human factors or design experts). This space for reflective learning (Lamont 2011)reached places that desk-based data analysis couldn't go. The key was in the quality of the clinical reviewers, the range of clincal and safety expertise at the weekly meetings and a national function with ability to act on the risks, once articulated in this forum. It would be a shame to lose this potential for learning from a few carefully selected incidents, with the right analytic and sense-making skills and resources, in justified criticism of the limited safety gains to date from large incident reporting systems.

  Tara Lamont Deputy Director NIHR Dissemination Centre

  Lamont Tara. "Re-cognising" risks: from space shuttles to chest drains BMJ 2011; 343 :d4393

  Conflict of Interest:

  I worked at the National Patient Safety Agency 2004-2011.

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  Conflict of Interest:
  None declared.

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• Published on: 13 May 2016

  Incident Reporting - Let's Decentralise

  • Merilyn A. Rees, Anaesthetist

  The Editor, BMJ Quality and Safety,

  Mitchell, Schuster, Smith et al (1) present the results of semi-structured interviews with 11 international patient safety experts, 15 years after publication of the US Institute of Medicine's landmark report 'To Err Is Human'.(2) One of the Institute's recommendations was the introduction of healthcare incident reporting.

  Qualitative analysis of the interviews by Mitchel...

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  The Editor, BMJ Quality and Safety,

  Mitchell, Schuster, Smith et al (1) present the results of semi-structured interviews with 11 international patient safety experts, 15 years after publication of the US Institute of Medicine's landmark report 'To Err Is Human'.(2) One of the Institute's recommendations was the introduction of healthcare incident reporting.

  Qualitative analysis of the interviews by Mitchell et al identified 5 problems - sheer volume of reports received and inadequate report processing, lack of involvement by medical practitioners, insufficient response and feedback to reports, inadequate funding and organizational backing, and failure to use electronic records. The article stated that the interviewees noted little progress in utilizing adverse event information to positively influence patient outcome - a sobering finding.

  In drawing on the opinion and experience of these national and international experts, maybe we are missing critical elements essential for utilization of incident reports. Their perspective and experience of incident reporting may have diluted or lost the value of this activity at the local healthcare facility. Taking anaesthesia as my example, reporting of adverse events and 'near misses' functions most robustly in the local department setting, where regular morbidity and mortality meetings allow free discussion of events in a 'no blame' culture. Knowledge of working conditions, staffing levels, rosters and surgical capabilities allows useful input regarding system factors involved in the incident, human factor analysis, and provision of feedback to people and the institution, in a timely fashion. Discussion of adverse events is a learning experience for everyone involved. The costs incurred by a department in the process of incident submission, analysis, discussion and feedback is minimal, as it is part of the contracted and expected duties of anaesthetic consultants and trainees. Trainees have evidence of reporting leading directly to tangible action, as closing the loop with feedback occurs soon after the incident. Anaesthesia incident reporting has become embedded in the functioning of my specialty at a departmental level, because it has addressed the identified problems - thus doctors do report, the data collected is processed, and feedback is provided in a timely fashion, the heads of department support and facilitate morbidity and mortality reporting, and minimal costs are incurred. Electronic record usage is utilised in some departments and will enhance audit and review when more readily available. Trainees are shown that safety and quality, with incident reporting, are integral parts of everyday practice, not an added extra, or afterthought.

  It is important that statewide and national reporting systems [Australian examples are Victorian Consultative Council on Anaesthetic Mortality and Morbidity (3), web-based reporting systems such as webAIRS (4)] are established, to identify patterns of failures or worrying trends in care, and recommend changes in practice. However, the considerable time-lag between adverse event occurrence, and their de-identified analysis and recommendations may reduce the impact of findings. The 5 problems identified by the interviewees are seen with these larger investigative bodies.

  Incident reporting is an essential part of health safety culture and climate (5), but to reap the benefits of the essential analysis and feedback components, I advocate decentralizing the process to craft groups and hospital departments. The manageable volume of reports, increased medical involvement, and feedback loops possible with smaller units would enhance learning and quality improvement.

  There is much to learn from incident reporting - we must not be buried under the pile of reports. We need to act locally, in our departments, our wards, our units, to promote and demand the collection of good data. We must provide the analysis and facilitate discussion of reports, and have safer and better quality care result from the feedback given.

  References

  1. Mitchell I, Schuster A, Smith K et al. Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after 'To Err is Human'. BMJ Quality and Safety Published Online First: 12th August 2015 doi:10.1136/bmjqs-2015-004405 Accessed 22nd August 2015

  2. Kohn L, Corrigan J, Donaldson M. To err is human: building a safer health system. Washington, DC. National Academy Press 2000.

  3. http://www.health.vic.gov.au/vccamm

  4. webAIRS: https://www.anztadc.net [Internet]: Accessed 7th September 2015

  5. Benn J, Koutantji M, Wallace L et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009;18(1):11-21

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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