Using Incident Reporting Systems to Improve Patient Safety and Quality of Care

1. Introduce incident reporting systems (IRS) as a concept to improve patient safety and quality of care

2. 2.

   Describe the characteristics of an IRS

3. Demonstrate the flow of incidents through the IRS and how it can be used in healthcare (case study).

Incidents are clinical or nonclinical events that have resulted in harm or could lead to a harmful or adverse event.^[1] In high-income countries, it is estimated that 1 in 10 patients experience an adverse event while receiving hospital care.^[2] Low- and middle-income countries (LMIC), especially, are experiencing a significant burden of death and disability due to incidents. An estimated 134 million adverse events are reported annually across hospitals in LMICs because of unsafe care.^[1,3,4] The reason for this is the significant number of patients who are either harmed or die each year because of unsafe healthcare. The magnitude may even be higher in these countries.

An Incident Reporting System (IRS0 is a way to report, document, investigate, and use the learning from incidents within the organization. It is ideal for identifying, reporting, and quickly managing any incidents or occurrences in a health service delivery that cause harm or have the potential to cause harm to patients. This is because reporting incidents allows hospitals to learn from these incidents and to improve the system that ensures patient safety.

Incident reporting systems (IRS; Fig. 1) should be an integral part of quality and safety processes in healthcare facilities. The system should be used to identify trends relating to patient care and the provision of a safe hospital environment for patients and staff.

The IRS aims to foster an open reporting and learning culture, acknowledging that lessons from incidents (errors, adverse/sentinel events, etc) must be shared to improve safety and apply best practices in managing risk to enhance the quality of care.

To identify the most critical risks to patient safety, healthcare facilities should have a dedicated team or committee to review and analyze reported incidents and organize a systematic, nonpunitive investigation into those incidents. The team or committee should be impartial and multidisciplinary, involving expertise from relevant clinical and nonclinical specialties.^[5]

We need a positive environment for reporting incidents. Promoting a “just culture” and an atmosphere of trust is essential to ensure all staff report incidents.^[5,6] Leadership, commitment, policies, and practical steps are necessary for creating a supportive and positive environment.^[2,4,7,8] The “just culture” should focus on the victim (patient or staff) and not on “the offender,” and there should be a transparent investigation (with no blame or retribution) focusing on where and why the incident happened and what should be done to prevent it from happening again.

Findings and learnings from the incidents should be shared across the organization. The reporting staff should also receive feedback from the incident analysis and investigation. Learnings from the incident should lead to redesigning policies, improving the process and procedures of care delivery, and improving the quality of care and the safety of patients. Any new changes to the healthcare system should be disseminated throughout the organization. Figure 1 demonstrates how incidents are managed through the IRS, and Table 1 shows some benefits of reporting incidents.

An effective incident reporting system requires the following key attributes:

1. An established policy, standard operating procedures, or terms of reference that guide incident reporting and management in the facility. This will create an awareness of the incident reporting process among staff

2. A common platform or tool for reporting incidents: The “incident reporting form” (Fig. 2) is a tool most facilities use to track and manage incidents. However, more sophisticated electronic systems allow staff to report and document incidents online and get investigated by a team to resolve issues identified. Automatic reports can also be generated periodically to monitor specific unit functions or institution-wide monitoring of certain incidents

3. There should be a supportive environment for event reporting. An atmosphere of trust that safeguards the privacy of staff who report incidents

4. A mechanism for incident categorization (near miss, adverse/sentinel events, or no harm events)

5. A multidisciplinary team or a committee to analyze, investigate, and monitor the trend of incidents within the organization

6. A structured mechanism to review incident reports and develop action plans

7. A mechanism to promptly disseminate learnings to staff and the organization

8. Have clear measures to evaluate the function and performance of the IRS (Table 2)

Nyaho Medical Centre (NMC) implements an IRS, which uses an electronic and an incident reporting form to report and document incidents. This helps the facility track all incidents and adverse events that occur in the hospital.

In 2018 and 2019, staff who had needlestick injuries during various patient care procedures reported the incident using the electronic and incident reporting form (Fig. 2), which provided a process for reporting and collecting data on incidents, adverse events, and near misses.

The incident report committee of NMC analyzed and investigated these incidents. A root cause analysis was conducted using the fishbone diagram to identify the contributing factors of the incident.^[6] The investigation revealed that there were no accessible sharps containers around the bed space for safe disposal, which meant that nurses had to walk distances to access designated containers to dispose of used needles. Also, there was no training on the safe disposal of needles and sharps, and there was evidence that recapping and other hand manipulations of needles existed among staff.

NMC initiated a quality improvement project to reduce the incidence of needlestick injuries among staff from 11 reported incidents in 2018 to 2 reported incidents in 2021 at NMC. Learning from the reported incidents was shared throughout the organization.

Having the IRS is critical for healthcare organizations to improve the quality of care and ensure patient safety. For effective use of the IRS, it is essential to have staff buy-in. The hospital should measure and report metrics on incidents regularly. This will help the facility to track the trends in frequently occurring or similar incidents. Findings and learning from reported incidents should be wider than the top management team. They should be disseminated throughout the organization to enhance quality service delivery and the safety of patients.