Ahluwalia and Marriott (2005) Critical Incident Reporting System18 | Neonatal Department (UK) | |
Regular monthly department safety bulletin that includes a fixed reminder of the unit’s agreed trigger list, summary of previous month’s critical incident reports, data on admissions and activity levels and a clinical lesson or guideline of the month |
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Amoore and Ingram (2002) Feedback notes for incidents involving medical devices47 | Medical equipment management in a 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 highlight positive actions taken by staff and provide anonymous information that allows staff to learn from why an incident occurred, in a supportive manner, while promoting a culture that supports learning |
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Beasley et al. (2004) Primary care medical error reporting system20 | Wisconsin Primary care (US) | Report submitters, upon reporting to the system, receive reminders, composite data or commentary to encourage a two-way flow of information |
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Bolsin (2005) and Bolsin et al. (2005) PDA-based Clinician-led reporting system49 50 | Anaesthesiology Australia and New Zealand College of Anaesthetists ANZCA (Australia) | |
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Gandhi et al. (2005) Safety Reporting System7 | Brigham and Women’s Hospital, Boston (US) | |
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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 60 | Hospital intensive care units—reporting centre at Johns Hopkins University School of Medicine (US) | |
Monthly feedback is used by ICU site team to identify local areas for improvement and each site receives text descriptions and system factors for all the incidents reported at the site, plus 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 |
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Information sharing with front-line staff is promoted through 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 |
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Joshi et al. (2002) Web-based incident reporting and analysis system21 | Baylor Healthcare System: Dallas, Texas (US) | |
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Le Duff et al. (2005) Incident Monitoring and Quality Improvement Process22 | Rennes Hospital, Brittany—Department of Radiology and Medical Imagery (France) | |
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Nakajima et al. (2005) & Takeda et al. (2003) Web-based/on-line incident reporting system53 58 | Osaka University Hospital (Japan) | |
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Oulton (1981) Incident reporting system54 | Virginia Hospitals Insurance Reciprocal (US) | |
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Incident reports are also passed to safety and quality-assurance committee for in-depth analysis and corrective action against safety problems, including the development of guidelines for hospital practice and governing the use of equipment, as well as nursing policy and changes to the equipment used in certain procedures |
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Parke (2003) Critical Incident Reporting System55 | General Intensive Care Unit, Reading (UK) | |
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Peshek et al. (2004) Voice-mail-based medication error reporting system23 | Summa Health System, Akron: Ohio (Medication administration) (US) | |
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Piotrowski et al. (2002) Safety Case Management Committee process56 | Veterans Affairs Ann Arbor Healthcare System (US) | |
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Poniatowski et al. (2005) Patient Safety Net (PSN) occurrence reporting system24 | University Health System Consortium (UHC) with over 90 members (US) | |
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Runciman et al. (2002), Beckmann et al. (1996) & Yong and Kluger (2003) Australian Incident Monitoring System (AIMS) and associated patient safety initiatives25 48 61 | Initially anaesthesia followed by all other specialty areas and hospital systems (Australia) | |
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Schaubhut and Jones (2000) Medication Error Reporting system26 | East Jefferson Memorial Hospital, Louisiana. Nursing Medication Administration Processes (US) | |
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Schneider and Hartwig (1994) Severity-indexed medication error reporting system27 | Ohio State University Medical Centre—Medication errors (pharmacy) (US) | Monthly reports from the incident database are generated to help identify problem areas according to severity-rated reports and categorisation according to unit of origin, error type, system breakdown and drug category |
Various forums and committees are responsible for reviewing medication error data to identify opportunities for improving patient care both within and across departments, including a quality-assurance committee which produces recommendations for physician’s practice, a pharmacy committee that addresses hospital-wide medications policy and a medication-error task force for specific issues |
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Silver (1999) Incident Review Management Process57 | All areas (US) | Disciplinary action taken against staff, where necessary, including: termination, counselling, suspension or written reprimand |
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Suresh et al. (2004) Medical error reporting system28 | Neonatal Intensive Care—Vermont Oxford Network (US) | |
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Tighe et al. (2006) Incident Reporting System19 | London Accident and Emergency Department Incident Reporting System (UK) | |
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Webster and Anderson (2002) Ward medication error reporting scheme29 | Hospital ward medicine administration (New Zealand) | |
Westfall et al. (2004) Web-based patient safety reporting system30 | Ambulatory primary care for rural and frontier communities (US) | |
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Clinical steering group met 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 recommendations developed to reduce the potential for that type of event |
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Wilf-Miron et al. (2003) Incident Reporting System59 | Maccabi 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 to ensure lessons are learnt on an individual level |
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