Table 1 Details of the feedback mechanisms and processes implemented in 12 of the 23 healthcare reporting systems described in the review, illustrating the range of strategies adopted
Reporting systemHealthcare domainDescription of information/action feedback mechanisms and processes
Ahluwalia and Marriott (2005) Critical Incident Reporting System18Neonatal Department (UK)
  • Regular multidisciplinary departmental meetings to discuss lessons learnt from reporting

  • Regular monthly department safety bulletin that includes summary of previous month’s critical incident reports and a clinical lesson or guideline of the month.

  • Individual email bulletins, paper-based newsletters or bulletins posted on department website

  • Targeted campaigns aimed at a specific incident or pattern of incidents

  • Investigation of identified safety issues through Root Cause Analysis and Failure Modes and Effects Analysis to identify system failures for remedial action

Amoore and Ingram (2002) Feedback notes for incidents involving medical devices47Medical equipment management in an NHS Trust (UK)
  • Feedback notes system developed as an educational tool to provide information on incident, equipment involved, causes and triggers uncovered by investigation, lessons learnt and positive actions taken by staff to minimise adverse consequences

  • Feedback notes issued to ward link nurses, used in teaching sessions and information disseminated to other hospital departments through annual nurse clinical update sessions and hospital intranet

Gandhi et al (2005) Safety Reporting System7Brigham and Women’s Hospital, Boston (US)
  • Feedback of issue progress by email to individual reporter and direct feedback of follow-up actions taken to original reporter to close the loop

  • Monthly article in staff bulletin to highlight safety issues

  • Safety improvements published quarterly in hospital newsletter

  • Monthly email circulated to front-line staff (anyone who reported) with summary of improvements made

  • Weekly reports of overdue follow-up on safety reports for nurse senior directors

  • Monthly patient safety leadership walkround visits

  • Quarterly report to higher levels of organisation including summary of actions taken to hospital leadership

  • Production of safety improvement actions and recommendations for follow-up, including prioritisation of opportunities and actions, assigning responsibility and accountability, and implementing the action plan

Holzmueller et al (2005); Lubomski et al (2004) & Wu et al (2002) Intensive Care Unit Safety Reporting System (ICUSRS)51 52 60Hospital intensive care units—reporting centre at Johns Hopkins University School of Medicine (US)
  • Monthly report sent to each participating ICU including quantitative data concerning the number of reports submitted in previous month compared with past year and individualised site data compared with data from across all study sites

  • Monthly data on total events to date, types of events reported and types of providers reporting for use at morbidity and mortality conferences, patient safety committees, hospital risk-management and hospital quality-improvement processes

  • Principal investigators at each site have the capability to access and query data submitted from their site for local analysis and to generate reports for use in quality-improvement activities using data analysis wizard

  • Information sharing with front-line staff is promoted through the use of staff bulletin board postings which accompany each monthly newsletter and which contain a summary of a safety issue raised, textual case examples, system failures identified and specific actions that may be taken to address them

  • Quarterly newsletter is distributed to staff at all study sites containing details of the project’s activities, focuses upon a common safety problem each issue and includes tips for improving safety

Joshi et al (2002) Web-based incident reporting and analysis system21Baylor Healthcare System: Dallas, Texas (US)
  • Systems solutions and improvements developed to address process and systems gaps identified

  • Follow-up actions are tracked by the IT system, which streamlines the data management and risk-identification process allowing more time for the design and implementation of improvement initiatives

  • User-controllable ad hoc querying of incident database and generation of reports

  • Educational feedback to enhance safety awareness through the use of case studies outlining hospital system successes and failures

  • Continuous communication with hospital staff through regular newsletters and department meetings to communicate patient safety data and what was being done with the data

Nakajima et al (2005) & Takeda et al (2005) Web-based/on-line incident reporting system53 58Osaka University Hospital (Japan)
  • Implementation of urgent improvement actions for high risk issues within a predetermined timescale

  • Patient safety seminars three times a year to inform all staff of findings from reporting systems and support a hospital-wide safety culture

  • Targeted staff education programmes linked to professional accreditation scheme

  • Ward rounds by peers and safety committee members to check safety improvements have been implemented

  • Safety-feedback information is made available to staff through hospital intranet, clinical risk manager’s monthly meetings (cascade) and mailing list

  • Paper-based and web-based newsletter alerts with topics chosen to coincide with media coverage of serious events and content includes commentary by hospital experts on specific issues

Piotrowski et al (2002) Safety Case Management Committee process56Veterans Affairs Ann Arbor Healthcare System (US)
  • Safety case management committee disseminates lessons learnt documents and action plans to higher-level authorising bodies (clinical executive board), a performance improvement committee and various other clinical committees and specialist bodies

  • Changes implemented in clinical systems, processes or policy revisions

  • Patient or clinician education campaigns

  • Monitoring of clinical systems or processes

  • Clinical communications produced

  • Staffing adjustment or supervision

Poniatowski et al (2005) Patient Safety Net (PSN) occurrence reporting system24University Health System Consortium (UHC) with over 90 members (US)
  • Direct action taken by nursing managers to ensure rapid patient safety improvement in response to reported issues

  • On-line event reporting tool allows nurses to share experiences of how they have improved patient safety in their units based upon directly actionable data provided by reporting system

  • Nurse managers receive immediate, real-time notification of safety events on their units

  • Managers can run their own local incident trend analysis reports

Runciman (2002), Beckmann et al (1996) & Yong et al (2003) Australian Incident Monitoring System (AIMS) and associated patient safety initiatives25 48 61Initially anaesthesia followed by all other specialty areas and hospital systems (Australia)
  • Preventive strategies devised on the basis of potential severity of impact and frequency of occurrence of contributory factors, as well as follow-up risk–benefit analysis to justify the resources used

  • Analysis of 2000 reported incidents in anaesthesia was published in 30 articles by 1992

  • Development of national standards and guidelines governing aspects of clinical practice, including equipment use and further monitoring of specific issues

  • Use of reported incident data to clarify and support problems identified with clinical equipment, leading to recall and modification of affected devices

  • De-identified data available for comparison across institutions and units

  • AIMS 2 web system employs cue-based retrieval that allows the user to rapidly retrieve a broad range of relevant incident reports

  • Newsletters, publications and advice at national level, feedback of improvement actions and evidence of action occurs at local level

Schaubhut and Jones (2000) Medication Error Reporting system26East Jefferson Memorial Hospital, Louisiana. Nursing Medication Administration Processes (US)
  • Brief summary information sheet “Hot Spots” is produced each month for nursing units containing information on trends in incident data along with opportunities for improvement

  • Improvement of medication administration policies to reduce causes of error undertaken based upon issues raised through reporting system

  • Immediate response to occurrence of a medication administration incident, when required

  • Mandatory medication error education programme was implemented for nursing and medical staff using examples of different incident types reported to hospital system

  • Personal study modules with written tests on local medication administration procedures are given in cases where training needs are identified from incidents

Westfall et al (2004) Web-based patient safety reporting system30Ambulatory primary care for rural and frontier communities (US)
  • Educational feedback to rural primary care practices based upon collection and analysis of medical error data

  • Implementation of interventions to improve patient safety: Principles for Process Improvement were developed for each identified safety area

  • Follow-up interviews scheduled with reporting staff, where necessary, to elicit further information

  • Clinical steering group meets in order to review data, direct additional study and create policy

  • Learning groups set up, comprising personnel from practices and project staff, in order to develop recommendations to tackle specific safety issues identified through reporting system data

  • For serious threats to patient safety, electronic and hard copy “alerts” were issued to all participants, briefly describing the event and associated recommendations

  • Periodic newsletter issued to practices

Wilf-Miron et al (2003) Incident Reporting System59Maccabi Healthcare Services—Ambulatory care service organisation (Israel)
  • Telephone hotline for reporting incidents and near misses, providing real-time dialogue with reporter to provide support, elaborate upon reported information and provide incident debriefing by professionals

  • Targeted training programs implemented on the basis of analysis of single and multiple events

  • Alteration of working practices and introduction of error reducing measures to ensure organisational learning based upon investigation of single incidents and analysis of data from multiple incidents

  • Manual on error prevention developed using practical examples of clinical adverse events

  • Full details of the 23 systems are reproduced in the online supplement.