Problems with incident reporting: Reports lead rarely to recommendations

Abstract

Aim and objective: To analyse trends in incident reporting over the last 5 years and determine how many reports led to recommendations?

Background: Patient safety incident reporting systems have been used in health care for years. However, they have a significant weakness in that reports often do not lead to any visible action.

Design: The study is a retrospective register study. STROBE checklist was applied in the preparation of the paper.

Methods: Data were collected from a web-based incident reporting database (HaiPro) for a social- and healthcare organisation in Finland, covering the period from 2011-2015.

Results: In total, 16,019 incident reports were analysed. In 2.7% (n = 426) of all reports, there was written recommendation to develop action that such incidents would not happen again. Those reports were classified into seven categories: education, introduction and information, introduction to work, patient care, guidelines, instruments and IT programmes, and the physical environment.

Conclusions: Managers get major amount incident reports. There should be (a) a definition what kind of events should be reported, (b) a definition for how serious events managers have to make a recommendation and (c) control that recommendations are implemented.

Relevance to clinical practice: There is a need for more action to promote patient safety based on incident reports.

Keywords: incident reporting; management; nursing; patient safety.