Authors' objectives: This review aims to assess the effectiveness of hospital incident reporting systems in improving hospital and clinic performance in terms of patient safety, clinical outcomes, costs, and operations.

Authors' recommendations: The following conclusions and recommendations result from this analysis: 1. Incident reporting can provide valuable qualitative and quantitative data relevant to incidents and adverse events, which in turn can potentially guide organizational and clinical interventions to decrease risks. 2. Despite more than 20 years of research in incident tracking and many countries implementing nationwide reporting systems, studies evaluating the reporting system's effectiveness are limited in number and tend to be qualitative and poorly controlled. This limits the evidence from which conclusions can be drawn. 3. The benefits of incident reporting in a health care environment are not well established. Although the quality improvement model on which incident reporting is founded is logical and has been proven effective in aviation and other non-medical industries, there is only limited scientific evidence of its benefits and effectiveness in a hospital setting. 4. The incident reporting systems reviewed in the literature appear to place more emphasis on reporting than on risk analysis and control. There is clearly a need for a more effective system that not only reports incidents, but also motivates organizational learning and process improvement. 5. The nature of incident reporting, which is subject to hindsight bias, lost information, and contextual clues because of recall, makes it unlikely that robust data will link it directly with improved outcomes unless carefully designed. 6. Incident reporting systems should include near misses; be non-punitive, confidential, or anonymous; involve multidisciplinary teams to investigate and improve care; focus on identifying aspects of the system that contribute to errors rather than blaming individuals; and provide feedback to all interested and involved parties. 7. Studies evaluating the effectiveness, cost, and reliability of incident reporting systems are very limited in number. The studies suggest that incident reporting systems provide a fairly inexpensive although incomplete means for monitoring patient safety and, when combined with systemic interventions, may be effective in reducing preventable incidents. 8. Any use of incident reporting should include pre- and post-test measures of medical error to better determine its effectiveness in enhancing patient care. Confounding factors should be controlled through study design, standardization, and appropriate outcome measures. 9. The use of incident reporting needs to be considered in the context of other standard approaches to promote and implement patient safety practices. 10. Alternative models for risk identification, including process mapping, direct observation, and medical record review, should be compared with incident reporting systems and combined with them to determine the most effective suite of tracking method(s) for monitoring adverse events, incidents, and near misses. 11. To successfully manage and minimize medical risk in institutions, a three-phase approach is required: risk identification, risk analysis, and risk control. 12. Patient safety research must be better designed to incorporate economic approaches, such as cost-benefit analysis, to show where hospitals resources can best be allocated.

Authors' methods: Overview

Project Status: Completed

Year Published: 2005

URL for published report: http://www.ihe.ca/advanced-search/institutional-medical-incident-reporting-systems-a-review

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: Canada

Organisation Name: Institute of Health Economics

Contact Address: 1200, 10405 Jasper Avenue, Edmonton, Alberta, Canada, T5J 3N4. Tel: +1 780 448 4881; Fax: +1 780 448 0018;

Contact Name: djuzwishin@ihe.ca

Contact Email: djuzwishin@ihe.ca

Copyright: <p>Alberta Heritage Foundation for Medical Research (AHFMR)</p>