The Problems with Incident Reporting

In 2012, the Office of the Inspector General published a report outlining the problems with incident reporting. Has anything changed since then? We think not.

7 25 Datix

In 2012, the Office of the Inspector General for the U.S. Department of Health and Human Services published a little-known report titled, “Hospital Incident Reporting Systems Do Not Capture Most Patient Harm.”

The Inspector General surveyed 189 hospitals – all of which had incident reporting systems that were relied heavily upon to capture events that were used to conduct patient safety improvement activities.

The report’s published findings show how much needs to be done – although this report was released six years ago, based on our experience, we don’t believe much has changed on the patient safety landscape. Consider the following discoveries offered up by the Inspector General, quoted verbatim from the 2012 report:

  • Hospital staff did not report 86 percent of events to incident reporting systems, partly because of staff misperceptions about what constitutes patient harm. Of the events experienced by Medicare beneficiaries discharged in October 2008, hospital incident reporting systems captured only an estimated 14 percent. In the absence of clear event reporting requirements, administrators classified 86 percent of unreported events as either events that staff did not perceive as reportable (62 percent of all events) or that staff commonly reported but did not report in this case (25 percent).
  • Nurses most often reported events, typically identified through the regular course of care; 28 of the 40 reported events led to investigations and five led to policy changes. Nurses most often identified events through patient observation and routine hospital safety assessments. Information regarding one-quarter of events was not accessible to the staff responsible for monitoring patient safety within the hospitals and for making policy changes. Hospitals investigated the events they considered most likely to yield information that would inform quality and safety improvement efforts and made few changes to policy or practices as a result of reported events.
  • Hospital accreditors reported that in evaluating hospital safety practices, they focus on how event information is used rather than how it is collected. Accreditors view incident reports within the context of larger hospital quality and patient safety efforts. Officials indicated that to assess hospitals, surveyors are most likely to review the results rather than review the methods used to track hospital adverse events. Surveyors would not specifically investigate these methods, such as incident reporting systems, unless evidence of a problem emerged through the survey process.

It’s Time To Go Beyond Simple Reporting

What we’ve learned over the years – not only Datix specifically, but healthcare as a while – is that protecting patients from harm requires active surveillance within a safety culture that encourages self-reporting of errors and near misses. It’s one thing to train your staff on what constitutes a patient safety event, but it’s another thing entirely to foster an organizational culture that fosters the reporting of these events.

To successfully reduce preventable patient harm, healthcare organizations need to do both.

It is for this reason that Datix designed its online incident reporting form in consultation with end users, so that it is simple to use and suitable for both clinical and non-clinical incident reporting. The user interface can be personalized to the needs of the organization, and the workflows can be amended to match the organization’s structure. Incidents can be submitted by anyone in the organization with access to a computer.

But we didn’t stop there, because reams of incident reports have no value on their own – regardless of whether they are stored in a file drawer or on a computer server. To be able to act on these reports require the ability to quickly identify trends, which is what the Datix Enterprise Risk Manager – a component of Datix Cloud IQ – is designed to do.

At the heart of Datix Cloud IQ is the Investigations module. With Investigations, you can uncover contributory factors that lead to incidents and efficiently devise recommendations and implement actions to protect patients. As issues are uncovered and improvements are implemented, organizational procedures are updated to embed the changes – giving your organization a memory of what works and why.

However, Datix Cloud IQ not only provides healthcare providers with the organizational memory they sorely need, but also encourages further incident reporting because staff see actions being taken to improve patient safety – actions that result from the reporting of incidents. When that happens, we’ve taken a big step to correct the problems identified by the Inspector General in 2012.