The Role of Incident-Reporting Systems in Improving Patient Safety in Japanese Hospitals: A Comparative Perspective

2021 ◽  
pp. 167-196
Author(s):  
Naonori Kodate ◽  
Ken’ichiro Taneda ◽  
Akiyo Yumoto ◽  
Yoshiko Sugiyama
Keyword(s):  
Patient Safety ◽  
Incident Reporting ◽  
Comparative Perspective ◽  
Incident Reporting Systems ◽  
Reporting Systems

scholarly journals Reflections on patient safety incident reporting systems

2021 ◽  
Vol 74 (suppl 1) ◽  
Author(s):  
Maria de Jesus Castro Sousa Harada ◽  
Ana Elisa Bauer de Camargo Silva ◽  
Liliane Bauer Feldman ◽  
Sheilla Siedler Tavares ◽  
Luiza Maria Gerhardt ◽  
...  
Keyword(s):  
Patient Safety ◽  
Reporting System ◽  
Data Entry ◽  
Incident Reporting ◽  
Incident Reporting Systems ◽  
System Method ◽  
Safety Incident ◽  
Reporting Systems ◽  
Patient Safety Incident ◽  
National Patient

ABSTRACT Objective: To reflect on the main characteristics and recommendations of Incident Reporting Systems, discuss the population’s participation in reporting, and point out challenges in the Brazilian system. Method: Reflection study, based on Ordinance No. 529/13, which instituted the National Patient Safety Program, under Collegiate Board Resolution (CBR) No. 36/13; reflections by experts were added. Results: Reporting systems are a source for learning and monitoring, allow early detection of incidents, investigations and, mainly, the generation of recommendations prior to recurrences, in addition to raising information for patients and relatives. There is little participation of the population in the reporting, regardless of the type of system and characteristics such as confidentiality, anonymity, and mandatory nature. Final Considerations: In Brazil, although reporting is mandatory, there is an urgency to advance the involvement and participation of the population, professionals, and institutions. To simplify data entry by improving the interface and importing data from the reporting system is an objective to be achieved.

Comparison of Patient Safety Incident Reporting Systems in Taiwan, Malaysia, and Indonesia

2020 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Inge Dhamanti ◽  
Sandra Leggat ◽  
Simon Barraclough ◽  
Hsun-Hsiang Liao ◽  
Nor'Aishah Abu Bakar
Keyword(s):  
Patient Safety ◽  
Incident Reporting ◽  
Incident Reporting Systems ◽  
Safety Incident ◽  
Reporting Systems ◽  
Patient Safety Incident ◽  
Safety Incident Reporting

scholarly journals Enhancing patient safety by integrating ethical dimensions to Critical Incident Reporting Systems

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
Kai Wehkamp ◽  
Eva Kuhn ◽  
Rainer Petzina ◽  
Alena Buyx ◽  
Annette Rogge
Keyword(s):  
Patient Safety ◽  
Clinical Ethics ◽  
Critical Incident ◽  
Critical Incidents ◽  
Incident Reporting ◽  
Biomedical Ethics ◽  
Incident Reporting Systems ◽  
Ethical Conflicts ◽  
Reporting Systems ◽  
Critical Incident Reporting

Abstract Background Critical Incident Reporting Systems (CIRS) provide a well-proven method to identify clinical risks in hospitals. All professions can report critical incidents anonymously, low-threshold, and without sanctions. Reported cases are processed to preventive measures that improve patient and staff safety. Clinical ethics consultations offer support for ethical conflicts but are dependent on the interaction with staff and management to be effective. The aim of this study was to investigate the rationale of integrating an ethical focus into CIRS. Methods A six-step approach combined the analysis of CIRS databases, potential cases, literature on clinical and organizational ethics, cases from ethics consultations, and experts’ experience to construct a framework for CIRS cases with ethical relevance and map the categories with principles of biomedical ethics. Results Four main categories of critical incidents with ethical relevance were derived: (1) patient-related communication; (2) consent, autonomy, and patient interest; (3) conflicting economic and medical interests; (4) staff communication and corporate culture. Each category was refined with different subcategories and mapped with case examples and exemplary related ethical principles to demonstrate ethical relevance. Conclusion The developed framework for CIRS cases with its ethical dimensions demonstrates the relevance of integrating ethics into the concept of risk-, quality-, and organizational management. It may also support clinical ethics consultations’ presence and effectiveness. The proposed enhancement could contribute to hospitals’ ethical infrastructure and may increase ethical behavior, patient safety, and employee satisfaction.

scholarly journals EVALUASI SISTEM PELAPORAN INSIDEN KESELAMATAN PASIEN DI RUMAH SAKIT

2018 ◽  
Vol 6 (2) ◽  
pp. 83
Author(s):  
Arfella Dara Tristantia
Keyword(s):  
Patient Safety ◽  
Incident Reporting ◽  
Safety Reporting ◽  
Descriptive Research ◽  
Incident Reporting Systems ◽  
Data Collection Process ◽  
Safety Incident ◽  
Reporting Systems ◽  
Patient Safety Incident ◽  
Incident Reports

Background: Incident reporting systems are designed to obtain information about patient safety and used for organizational and individual learning.Aims: The objective is to evaluate the implementation of patient safety incident reporting system at a hospital of Surabaya.Method: This study was an observational descriptive research supported by qualitative data. This study used Health Metrics Network (HMN) model.Results: The results of the input evaluation show that there was a policy that regulates the incident report, but its implementation was still not appropriate with no direct funding. However, facilities were provided for reporting. There were socialization for employees who have different understanding and responsibility, organizational structure of the patient safety team, problem solving method which had not used PDSA (Plan, Do, Study, Action), and computerized technology.Conclusion: The process evaluation shows that the indicators were in line with the rules. The data sources were in accordance with the guidelines. Data collection, process, presentation, and analysis were in line with the theory. The output evaluation shows the submission of incident reports had not been timely. Moreover, the report was complete and suitable to the existing guidelines, and it had been used for decision-making. It is required for the hospital to revise the guidebook of incidence reporting and improve the human resource skill.Keywords: evaluation, incident, patient safety, reporting

scholarly journals What to do with healthcare Incident Reporting Systems

2013 ◽  
Vol 2 (3) ◽  
pp. 27 ◽  
Author(s):  
Julius Cuong Pham ◽  
Thierry Girard ◽  
Peter J. Pronovost
Keyword(s):  
Patient Safety ◽  
Patient Safety Culture ◽  
Local System ◽  
Error Rates ◽  
Incident Reporting ◽  
Organizational Level ◽  
Voluntary Reporting ◽  
Incident Reporting Systems ◽  
Reporting Systems ◽  
Changes Over Time

Incident Reporting Systems (IRS) are and will continue to be an important influence on improving patient safety. They can provide valuable insights into how and why patients can be harmed at the organizational level. However, they are not the panacea that many believe them to be. They have several limitations that should be considered. Most of these limitations stem from inherent biases of voluntary reporting systems. These limitations include: i) IRS can’t be used to measure safety (error rates); ii) IRS can’t be used to compare organizations; iii) IRS can’t be used to measure changes over time; iv) IRS generate too many reports; v) IRS often don’t generate in-depth analyses or result in strong interventions to reduce risk; vi) IRS are associated with costs. IRS do offer significant value; their value is found in the following: i) IRS can be used to identify local system hazards; ii) IRS can be used to aggregate experiences for uncommon conditions; iii) IRS can be used to share lessons within and across organizations; iv) IRS can be used to increase patient safety culture. Moving forward, several strategies are suggested to maximize their value: i) make reporting easier; ii) make reporting meaningful to the reporter; iii) make the measure of success system changes, rather than events reported; iv) prioritize which events to report and investigate, report and investigate them well; v) convene with diverse stakeholders to enhance the value of IRS.

Impact of an electronic health record transition on chemotherapy error reporting

2019 ◽  
Vol 26 (4) ◽  
pp. 787-793
Author(s):  
Elizabeth Hess ◽  
Shannon E Palmer ◽  
Andrew Stivers ◽  
Lindsey B Amerine
Keyword(s):  
Patient Safety ◽  
Electronic Health Record ◽  
Medication Error ◽  
Medication Use ◽  
Incident Reporting ◽  
Error Reporting ◽  
Health Record ◽  
Incident Reporting Systems ◽  
Reporting Systems ◽  
Electronic Health

Background Incident reporting systems allow for frontline employees to report errors and are a critical component of healthcare patient safety programs. Although incident reporting systems cannot quantify total errors, organizations can utilize incident reporting systems to help identify risks and trends to act upon. The objective of this article is to utilize incident reporting systems to evaluate trends in medication error reporting before and after implementation of a new electronic health record system. Methods A five-month pre- and post-analysis was completed in a cancer hospital following electronic health record conversion by reviewing medication errors reported via the institution’s voluntary incident reporting systems. Error reports included medication error category, date error was reported/occurred, patient location at time of error, harm severity score, medication(s) involved, medication use system node error originated/discovered in, medication source, narrative summary, and contributing factors. Data were analyzed using descriptive statistics within Office Excel. Results Oncology medication error reports submitted pre- and post-electronic health record were 68 vs. 57, respectively. During the pre- and post-electronic health record conversion, a majority of errors had a harm severity index of 0 or 1; 12 (18%) in pre-electronic health record and 3 (5%) in post-electronic health record were level 2, and one (1%) in pre-electronic health record vs. 0 in post-electronic health record were level 3. Reported medication errors originated most commonly during the prescribing, administration, and preparation/dispensing phase and were primarily identified in the administration phase of the medication use process. The most frequently reported error category was ‘wrong dose’ followed by ‘other’ and ‘overdose’ in the pre-electronic health record phase and ‘missing dose/delayed delivery’ and ‘order incorrect’ in the post-electronic health record phase. The most frequently reported medications included methotrexate, chemotherapy (unspecified), and cisplatin. Conclusion Analyzing data from incident reporting system reports allowed our institution to understand different trends of reporting in the cancer hospital following electronic health record adoption. Utilization of incident reporting systems must be combined with proactive risk identification approaches to enable systems-focused improvements to improve patient safety.

Improving patient safety incident reporting systems by focusing upon feedback – lessons from English and Welsh trusts

2009 ◽  
Vol 22 (3) ◽  
pp. 129-135 ◽  
Author(s):  
Louise M Wallace ◽  
Peter Spurgeon ◽  
Jonathan Benn ◽  
Maria Koutantji ◽  
Charles Vincent
Keyword(s):  
Health Care ◽  
Patient Safety ◽  
High Risk ◽  
Health Services ◽  
Incident Reporting ◽  
Incident Reporting Systems ◽  
Safety Incident ◽  
Reporting Systems ◽  
Patient Safety Incident ◽  
Safety Incident Reporting

This paper describes practical implications and learning from a multi-method study of feedback from patient safety incident reporting systems. The study was performed using the Safety Action and Information Feedback from Incident Reporting model, a model of the requirements of the feedback element of a patient safety incident reporting and learning system, derived from a scoping review of research and expert advice from world leaders in safety in high-risk industries. We present the key findings of the studies conducted in the National Health Services (NHS) trusts in England and Wales in 2006. These were a survey completed by risk managers for 351 trusts in England and Wales, three case studies including interviews with staff concerning an example of good practice feedback and an audit of 90 trusts clinical risk staff newsletters. We draw on an Expert Workshop that included 71 experts from the NHS, from regulatory bodies in health care, Royal Colleges, Health and Safety Executive and safety agencies in health care and high-risk industries (commercial aviation, rail and maritime industries). We draw recommendations of enduring relevance to the UK NHS that can be used by trust staff to improve their systems. The recommendations will be of relevance in general terms to health services worldwide.

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