Incident Report: Between the Shadows of Obligation and Formality
DOI:
https://doi.org/10.3889/oamjms.2021.5949Keywords:
incident report, Staff Role, Management, Health Information, Quality, Patient Safety, Hospital Incident ReportingAbstract
BACKGROUND: Incident reports are the primary data source for monitoring patient safety in the hospital. Monitoring of these reports determines the success of managing safety-related incidents as an effort to improve patient care. Hospital staff plays an essential role in the management of incident reports. Each staff member has a role in managing incident reports.
AIM: This article aimed to explore the role of hospital staff in the incident reporting process.
METHODS: This qualitative research used an exploratory approach. The research informants were three doctors, 21 nurses, one pharmacist, and two computer administrators. Data were collected using interviews and observations of incident reporting implementation. The research data were analyzed with the qualitative analysis software Atlas.ti.
RESULTS: Report management is not done solely for the formality of achieving the target. Implementation of regulations for report management is also done by all hospital staff to prioritize discipline, honesty, and responsibility according to their roles. Staff is expected to report adverse or dangerous events (incidents) that could affect patient safety. The reporting coordinator is responsible for the report’s completeness. Heads of participation room are expected to validate reports. The patient safety team is in charge of analyzing and providing feedback. Supportive attitudes from the board of directors are needed to create a reporting culture. There are several barriers to reporting management, including management support factors, facilities, and an effective feedback system.
CONCLUSION: Leaders need to develop staff who focus on discipline, honesty, and responsibility in providing services to patients by prioritizing patient safety. All staff is involved in managing incident reports by playing an active role in following their duties.Downloads
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References
The Joint Commission. Patient Safety Systems. Vol. 1. Oakbrook Terrace, Illinois: The Joint Commission; 2019.
Armitage G, Moore S, Reynolds C, Laloë PA, Coulson C, McEachan R, et al. Patient-reported safety incidents as a new source of patient safety data: An exploratory comparative study in an acute hospital in England. J Health Serv Res Policy. 2018;23(1):36-43. https://doi.org/10.1177/1355819617727563 PMid:29235364 DOI: https://doi.org/10.1177/1355819617727563
Budi SC, Sunartini, Lazuardi L, Dewi FS. Information systems and patient safety incident reports: A systematic review of literature and observational incident reporting system in hospitals. Int J Recent Technol Eng. 2019;8(1):807-14.
World Health Organization. WHO Draft Guidelines for Adverse Event Reporting and Learning Systems. Vol. 16. Geneva, Switzerland: World Health Organization; 2006. p. 80.
World Health Organization. Forward Programme 2008-2009. Geneva, Switzerland: World Health Organization; 2009.
NHS Improvement. NRLS National Patient Safety Incident Reports: Commentary. London: NHS Improvement; 2018.
Panesar SS, Carson-Stevens A, Salvilla SA, Sheikh A. Patient Safety and Healthcare Improvement at a Glance. Hoboken, New Jersey: Wiley; 2014.
Wagner C, Merten H, Zwaan L, Lubberding S, Timmermans D, Smits M. Unit-based incident reporting and root cause analysis: Variation at three hospital unit types. BMJ Open. 2016;6(6):11277. https://doi.org/10.1136/bmjopen-2016-011277 DOI: https://doi.org/10.1136/bmjopen-2016-011277
Hewitt T. Hospital-Based Views and Practices to Incident Reporting and Patient Safety: A Qualitative Comparative Study of Two Divisions; 2015. DOI: https://doi.org/10.5465/ambpp.2015.11777abstract
Farr BC. Qualitative Research Methods: A Data Collector’s Field Guide. Vol. 25. Durham, North Carolina: Family Health International; 2008.
Braun V, Clarke V. Snowball sampling completion Irina- Maria Dragan, Alexandru Isaic-Maniu. J Stud Soc Sci. 2013;5(2):160-77.
Joint Commission International. Joint Commission International Accreditation Standards for Hospitals Standards-only Version. Oakbrook Terrace: Joint Commission International; 2014. p. 35. https://doi.org/10.37573/9781585284474.002 DOI: https://doi.org/10.37573/9781585284474.002
Matthew AM, Miles B. Qualitative Data Analysis: An Expanded Sourcebook; 1994. Available from: https://www.books.google.co.id/books?hl=en&lr=&id=U4lU_-wJ5QEC&oi=fnd&pg=PA10&dq=buku+miles+dan+huberman&ots=kFTD_IVY_U&sig=F-NFGRPh58xZSOcKyhQh23WyT3Y&redir_esc=y#v=onepage&q&f=false. [Last accessed on 2021 Feb 23].
Carter N, Bryant-Lukosius D, Dicenso A, Blythe J, Neville AJ. The use of triangulation in qualitative research. Oncol Nurs Forum. 2014;41(5):545-7. https://doi.org/10.1188/14.onf.545-547 PMid:25158659 DOI: https://doi.org/10.1188/14.ONF.545-547
Ramírez E, Martín A, Villán Y, Lorente M, Ojeda J, Moro M, Vara C, et al. Effectiveness and limitations of an incident-reporting system analysed by local clinical safety leaders in a tertiary hospital: Prospective evaluation through real-time observations of patient safety incidents. Med (United States). 2018;97(38):e12509. https://doi.org/10.1097/md.0000000000012509 PMid:30235764 DOI: https://doi.org/10.1097/MD.0000000000012509
Heideveld-chevalking AJ, Calsbeek H, Damen J, Gooszen H, Wolff AP. The impact of a standardised incident reporting system in the perioperative setting: A single center experience on 2,563 “near-misses” and adverse events. Patient Saf Surg. 2014;8(1):46. https://doi.org/10.1186/preaccept-1149944930147258 PMid:25632301 DOI: https://doi.org/10.1186/PREACCEPT-1149944930147258
National Health Service. Incident Reporting Policy and Procedure. United Kingdom: National Health Service; 2020.
Wami SD, Demssie AF, Wassie MM, Ahmed AN. Patient safety culture and associated factors: A quantitative and qualitative study of healthcare workers’ view in Jimma zone Hospitals, Southwest Ethiopia. BMC Health Serv Res. 2016;16:495. https://doi.org/10.1186/s12913-016-1757-z PMid:27644960 DOI: https://doi.org/10.1186/s12913-016-1757-z
Department Health Republic of South Africa. National Guideline for Patient Safety Incident Reporting and Learning in the Public Health Sector of South Africa April 2017. Pretoria, South Africa: Department Health Republic of South Africa; 2017. https://doi.org/10.1163/2213-2996_flg_com_172084 DOI: https://doi.org/10.1163/2213-2996_flg_COM_172084
Danielsson M, Nilsen P, Rutberg H, Årestedt K. A national study of patient safety culture in hospitals in Sweden. J Patient Saf. 2019;15(4):328-33. https://doi.org/10.1097/pts.0000000000000369 PMid:28234728 DOI: https://doi.org/10.1097/PTS.0000000000000369
Holden RJ, Karsh BT. Applying a Theoretical Framework to the Research and Design of Medical Error Reporting Systems. Healthcare System Ergonomics Patient Safety Human Factor, a Bridge Between Care Cure Proceeding International Conference HEPS; 2005. p. 131-4; 2014.
Reed S, Arnal D, Frank O, Gomez-Arnau JI, Hansen R, LesterO, et al. National critical incident reporting systems relevant to anaesthesia: A European survey. Br J Anaesth. 2014;112(3):546-55. https://doi.org/10.1093/bja/aet406 PMid:24318857 DOI: https://doi.org/10.1093/bja/aet406
World Health Organization. Minimal Information Model for Patient Safety Incident Reporting and Learning Systems. Geneva: World Health Organization; 2016.
Farley DO, Damberg CL. Evaluation of the AHRQ Patient Safety Initiative: Synthesis of Findings. 2008;44(2 Pt 2):756-76. PMid:21456115 DOI: https://doi.org/10.1111/j.1475-6773.2008.00939.x
Minnesota Department of Health. Adverse Health Events in Minnesota. in Adverse Health Events in Minnesota. Minnesota: Minnesota Department of Health; 2018. p. 141-60. https://doi.org/10.4324/9781315167596-10 DOI: https://doi.org/10.4324/9781315167596-10
Elliott P, Martin D, Neville D. Electronic clinical safety reporting system: A benefits evaluation. JMIR Med Inform. 2014;2(1):e12. https://doi.org/10.2196/medinform.3316 PMid:25600569 DOI: https://doi.org/10.2196/medinform.3316
Hwang JI, Lee SI, Park HA. Barriers to the operation of patient safety incident reporting systems in Korean general hospitals. Healthc Inform Res. 2012;18(4):279-86. https://doi.org/10.4258/hir.2012.18.4.279 PMid:23346479 DOI: https://doi.org/10.4258/hir.2012.18.4.279
Dekker S. Patient Safety a Human Factors Approach. London: CRC Press; 2011. DOI: https://doi.org/10.1016/S2155-8256(15)30263-5
Cima RR, Lackore KA, Nehring SA, Cassivi SD, Donohue JH, Deschamps C, et al. How best to measure surgical quality? comparison of the agency for healthcare research and quality patient safety indicators (AHRQ-PSI) and the American college of surgeons national surgical quality improvement program (ACS-NSQIP) postoperative adverse events at a single institution. Surgery. 2011;150(5):943-9. https://doi.org/10.1016/j.surg.2011.06.020 PMid:21875734 DOI: https://doi.org/10.1016/j.surg.2011.06.020
Harkanen M, Saano S, Vehvilainen-Julkunen K. Using incident reports to inform the prevention of medication administration errors. J Clin Nurs. 2017;26(21-22):3486-99. https://doi.org/10.1111/jocn.13713 PMid:28042673 DOI: https://doi.org/10.1111/jocn.13713
Derosier J, Stalhandske E, Bagian JP, Nudell T. Using health care failure mode and effect analysisTM: The VA national center for patient safety’s prospective risk analysis system. J Qual Improv. 2002;28(5):248-67, 209. https://doi.org/10.1016/s1070-3241(02)28025-6 PMid:12053459 DOI: https://doi.org/10.1016/S1070-3241(02)28025-6
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Copyright (c) 2021 Savitri Citra Budi, Sunartini Hapsara, Fatwa Sari Tetra, Lutfan Lazuardi (Author)
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