Adverse event reporting.pdf

A higher level of structured reporting asks reporters to select options from defined
fields as part of the reporting process. This can greatly facilitate input into datasets
developed for analysis. The Australian Patient Safety Foundation’s Advanced Incident
Management System (AIMS), offers a highly sophisticated customizable data entry
form that guides users through a cascade of natural questions and response choices
that are structured and consistent.
However, much of what promotes learning in patient safety lacks crisply defined
data elements, so most authorities believe it is important for reports to include narrative
to convey meaning. Narrative reports provide the opportunity to capture the
rich context and storyline that allow the conditions that contributed to the error to
be explored and understood. Indeed, some believe that only narrative reports are
capable of providing information that provides meaningful insight into the nature
of the underlying systems defects that caused the incident (Richard Cook, personal
communication).
The vast majority of reporting forms have at least some room for a narrative
description, and some, such as the United States Food and Drug Administration
(FDA) MedWatch programme include open narrative for other relevant medical
information such as laboratory data or patient condition.
Because of the nature of analysis that is required, systems that elicit open-ended,
narrative texts require additional resources for data analysis and interpretation. In
contrast, reports to systems with a standardized format, fixed fields, and predefined
choices are swiftly entered and readily classified, making possible aggregated analysis
at lower cost.
Another consideration is the effect of reporting on the reporter. Providing reporters
with the chance to tell their stories implicitly values their observations. When the
reporter can trust in a considered and non-punitive response, the process raises the
individual’s awareness of patient safety and sense of responsibility for reporting.
Classification
Reporting of events is of little value unless the data are analysed. Regardless of
the objective of the system – whether to identify new and previously unsuspected
hazards, discover trends, prioritize areas for remedial efforts, uncover common
contributing factors, or develop strategies to decrease adverse events and patient
harm – neither the act of reporting nor the collection of data will accomplish that
objective unless the data are analysed and recommendations are made for change.
Classification of the event is the first step in the analysis.