Unit-based incident reporting and root cause analysis: variation at three hospital unit types
Authors : Cordula Wagner, Hanneke Merten, Laura Zwaan, Sanne Lubberding, Danielle Timmermans, Marleen Smits
Abstract
Objectives
To minimise adverse events in healthcare, various large-scale incident reporting and learning systems have been developed worldwide. Nevertheless, learning from patient safety incidents is going slowly. Local, unit-based reporting systems can help to get faster and more detailed insight into unit-specific safety issues. The aim of our study was to gain insight into types and causes of patient safety incidents in hospital units and to explore differences between unit types.
Design Prospective observational study.
Setting
10 emergency medicine units, 10 internal medicine units and 10 general surgery units in 20 hospitals in the Netherlands participated. Patient safety incidents were reported by healthcare providers. Reports were analysed with root cause analysis. The results were compared between the 3 unit types.
Results
A total of 2028 incidents were reported in an average reporting period of 8 weeks per unit. More than half had some consequences for patients, such as a prolonged hospital stay or longer waiting time, and a small number resulted in patient harm. Significant differences in incident types and causes were found between unit types. Emergency units reported more incidents related to collaboration, whereas surgical and internal medicine units reported more incidents related to medication use. The distribution of root causes of surgical and emergency medicine units showed more mutual similarities than those of internal medicine units.
Conclusions
Comparable incidents and causes have been found in all units, but there were also differences between units and unit types. Unit-based incident reporting gives specific information and therefore makes improvements easier. We conclude that unit-based incident reporting has an added value besides hospital-wide or national reporting systems that already exist in various countries.
Citation: Cordula Wagner, Hanneke Merten, Laura Zwaan, Sanne Lubberding, Danielle Timmermans, Marleen Smits Unit-based incident reporting and root cause analysis: variation at three hospital unit types
BMJ Open 2016;6:e011277 doi:10.1136/bmjopen-2016-011277
Received: 22 February 2016 Revised: 26 April 2016 Accepted: 20 May 2016 Published: 21 June 2016
Copyright: This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Contributors
CW, LZ, DT and MS contributed to the design of the study. HM, LZ, SL and MS collected the data. CW and DT supervised the data collection. CW and MS performed the data analyses and drafted the manuscript. HM, LZ, SL and DT revised the manuscript critically for important intellectual content. All the authors read and approved the final manuscript and are accountable for the work.
Funding This work was financially supported by the Dutch Ministry of Health, Welfare and Sport.
Competing interests None declared.
