Pediatric Informatics: Computer Applications in Child Health (Health ...

388 D.C. Stockwell and A.D. Slonim
Table 30.2 Critical steps in increasing error reporting
Institute timely investigation, actions and communication after errors are identified
Focus on improving systems rather than blaming individuals
Encourage identification and documentation of errors without punitive repercussions
Establish anonymous, accessible and redundant (paper and electronic) error/incident
reporting systems
Benchmark system performance (“Days without an accident”) and report to staff
30.4.1 Root Cause Analysis (See Chapter 29)
30.4.2 Chart Review
The oldest form of error/adverse event detection is random audits of the medical
record. This method arose out of retrospective research projects designed to
identify medical errors. This process is time consuming, has low yield, relies upon
a small sample size, is expensive and has considerable interobserver variability. 11
However, this method is more sensitive in identifying individual errors. This
method is not typically utilized outside of the research setting due to its high cost
and large amount of labor required to identify errors. 11
30.4.3 Incident Reporting
Incident reporting involves completing a standard report about an adverse event
after it has occurred. This report is then routed for review to assess quality and
safety process breakdowns leading to error. Incident reports are the most commonly
available data upon which patient safety improvements are made. These reports are
typically monitored by the hospital’s risk management department.
From performance improvement and research perspectives, incident reports are
inadequate because of their inherent biases. First, incident reports represent only
the “tip of the iceberg” in terms of the events that are reported. 12 It is estimated that
this method identifies approximately 5% of all hospital errors. 11 Second, there are
biases associated with what is reported and more importantly, what is not reported.
Finally, like many aspects of any safe healthcare environment, incident reporting
also depends on a positive cultural norm that encourages reporting. 13 Practitioners
are less likely to report if they believe the filing will lead to blame to either them or
a colleague for the adverse outcome. 13 Further, safety programs and interventions
that are implemented based on these rare events may actually perturb the system of
care further and lead to adverse events in other areas. Nonetheless, incident reports
provide fundamental information on what the front line staff believes are important
issues. Practitioners and staff who take the time to complete incident reports need
support and regular feedback on the types and frequencies of reported errors and
need a system in place for correcting the identified errors. 13