Patient safety incident capture resulting from incident reports: a comparative observational analysis

Authors: Martin A Reznek, Kevin A Kotkowski, Michael W Arce, Zachary K Jepson, Steven B Bird and Chad E Darling

Abstract

Background

Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs.

Methods

A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups.

Results

363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p < 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs.

Conclusion

HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. Further research is warranted to develop effective strategies to improve the utility of incident reports from both HCPs and non-HCPs.

Keywords: Incident reporting; Quality improvement; Patient safety; Emergency medicine

Citation: Martin A Reznek, Kevin A Kotkowski, Michael W Arce, Zachary K Jepson Patient safety incident capture resulting from incident reports: a comparative observational analysis BMC Emergency Medicine 2015, 15:6  doi:10.1186/s12873-015-0032-7

Received: 19 March 2014 Accepted: 24 March 2015 Published: 11 April 2015

Copyright: © 2015 Reznek et al.; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

MAR developed the study concept and design, acquired, analysed and interpreted the data, drafted the manuscript and supervised the study; KAK analysed and interpreted the data and critically revised the manuscript for important intellectual content; MWA acquired the data and assisted with drafting the manuscript; ZKJ acquired the data and assisted with drafting the manuscript; SBB performed statistical analysis of the data and critically revised the manuscript for important intellectual content; CED analysed and interpreted the data, drafted the manuscript and supervised the study. All authors participated in the peer review committee. All authors read and approved the final manuscript.

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