Implementing an Intervention to Improve Adverse Incident Reporting in the Hospital Setting: A Pilot Study
Abstract BackgroundTo improve patient safety, it is needed to collect information related to adverse events and near-miss reports. This practice constitutes one of the strategies hospital managers use to understand the kinds of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting rates among physicians. MethodsThe study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and consisted of the four following steps: defining reporting standards, improving the incident reporting system, having the hospital administrators set clear goals and beginning a visualized feedback process, and achieving support and appropriate feedback as a leadership resource from the hospital administrator. ResultsPhysicians’ reporting rates were higher in FY 2018 than 2017. Particularly, differences began to occur in November of FY 2018 (p < 0.05, analyzed using Fisher’s exact test). Further, the number of reports submitted by non-physicians increased by 900 in FY 2018 compared to those in FY 2017. Physicians tend to underreport minor incidents, but reports of near-miss events increased from 16 in FY 2017 to 106 in FY 2018. Reporting standards were focused on severe cases, but they had related treatment/procedure and drug, so that not only error cases but also near-miss cases were reported. Based on these results, the intervention effectively increased incident reporting rates among not only physicians, but also other staff members. In this regard, reporting barriers were broken when hospital administrators encouraged employees to submit incident reports.ConclusionsActive intervention of hospital administrators, the executive class of the hospital, may encourage employees to submit incident reports, thus effectively removing reporting barriers.