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Learning From Incident Reporting? Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care.
J Patient Saf. 2020 12; 16(4):264-268
Publication Type
Journal Article
Eva-Lena Ahlberg
Johan Elfström
Madeleine Risberg Borgstedt
Annica Öhrn
Christer Andersson
Rune Sjödahl
Per Nilsen
Author Affiliation
From the Center for Healthcare Development, County Council of Östergötland.
J Patient Saf. 2020 12; 16(4):264-268
Publication Type
Journal Article
Learning Health System - methods
Patient Safety - standards
Risk Management - methods
Incident reporting (IR) systems have the potential to improve patient safety if they enable learning from the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council.
The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence.
Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline.
The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.
PubMed ID
29112034 View in PubMed
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