Background. Incident Reporting (IR) is an essential tool for identifying and analyze healthcare related risks is a marker of the attention to patient safety. IR highlights error’s predisposing conditions and improvement opportunities. Objects and Methods. The aim of the study was to analyze the characteristics of the IR in a large academic hospital (2009-2014). Reported events (REs) were anonymous and included the following (not mandatory) information: ate, day of the week, time slot (morning, afternoon and night shift), reporter’s ward (Medical, Surgical, Diagnostics, Intensive Care Unit [ICU], Operating Rooms [OR]) reporter’s role (Doctor, Nurse, Other), incident description, patient age, patient sex, event occurrence (Adverse Event, Near Miss). Results. A total of 4698 REs were collected, corresponding to 1 every 56 discharges (264869/4698), with an average of 783 IR per year; 34,4% (1618) were dverse events, 40,9% (1923) near misses. IR distribution during the week progressively increased from Monday to Wednesday (peak of 17,0% of REs [803]) then decreased towards weekend (4,4% [353] on Sunday). The time slot analysis showed a peak of REs during morning shift (42,1% [1977]) with a decrease in afternoon (22,3% [1049]) and night (7,1% [332]) shifts. REs came for 29,5% (1387) from Medical wards, 24,7% (1159) from Diagnostics, 20,8% 975) from Surgical wards, 11,2% (524) from ICU and 6,8% (319) from OR. Reporter’s role was for 49,3% (2315) nurse, for 26,2% (1232) doctors and 17,7% (832) others. Comparing reporter’s role with professionals full time uivalent (FTE) we had 1 IR every 3,7 nurse, 1 every 3,3 doctors and 1 every 12, 8 others. Conclusions. The number of REs showed an elevated attention to patient safety. IRs distribution during week and time slot seemed to follow hospital level of activity. Medical wards according to the literature seemed the main setting for reported adverse events. Contrary to literature, doctors seemed more inclined to REs than nurses.
Incident reporting patterns: a five year experience
BRUSAFERRO, Silvio
2015-01-01
Abstract
Background. Incident Reporting (IR) is an essential tool for identifying and analyze healthcare related risks is a marker of the attention to patient safety. IR highlights error’s predisposing conditions and improvement opportunities. Objects and Methods. The aim of the study was to analyze the characteristics of the IR in a large academic hospital (2009-2014). Reported events (REs) were anonymous and included the following (not mandatory) information: ate, day of the week, time slot (morning, afternoon and night shift), reporter’s ward (Medical, Surgical, Diagnostics, Intensive Care Unit [ICU], Operating Rooms [OR]) reporter’s role (Doctor, Nurse, Other), incident description, patient age, patient sex, event occurrence (Adverse Event, Near Miss). Results. A total of 4698 REs were collected, corresponding to 1 every 56 discharges (264869/4698), with an average of 783 IR per year; 34,4% (1618) were dverse events, 40,9% (1923) near misses. IR distribution during the week progressively increased from Monday to Wednesday (peak of 17,0% of REs [803]) then decreased towards weekend (4,4% [353] on Sunday). The time slot analysis showed a peak of REs during morning shift (42,1% [1977]) with a decrease in afternoon (22,3% [1049]) and night (7,1% [332]) shifts. REs came for 29,5% (1387) from Medical wards, 24,7% (1159) from Diagnostics, 20,8% 975) from Surgical wards, 11,2% (524) from ICU and 6,8% (319) from OR. Reporter’s role was for 49,3% (2315) nurse, for 26,2% (1232) doctors and 17,7% (832) others. Comparing reporter’s role with professionals full time uivalent (FTE) we had 1 IR every 3,7 nurse, 1 every 3,3 doctors and 1 every 12, 8 others. Conclusions. The number of REs showed an elevated attention to patient safety. IRs distribution during week and time slot seemed to follow hospital level of activity. Medical wards according to the literature seemed the main setting for reported adverse events. Contrary to literature, doctors seemed more inclined to REs than nurses.I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
