BACKGROUND
Patient safety, reducing medical errors and risk management have become a global public health and administrative issue. Population-based studies around the world have alerted high rates of preventable medical errors and deaths. In response, a global effort agreed on a World Health Assembly resolution on patient safety. The World Alliance for Patient Safety guideline and the Conceptual Framework for the International Classification for Patient Safety have been launched by the World Health Organization (WHO) to galvanize and facilitate efforts by all Member States to make health care safer. The guidelines introduced adverse event reporting and focus on reporting and learning to improve the safety of patient care. The WHO suggested a conceptual framework for patient safety providing comprehensive understanding of the domains of patient safety. It represents a continuous learning and improvement cycle emphasizing on proactive (identification of risk, prevention, detection, reduction of risk) and reactive (incident recovery, system resilience) risk management. The ultimate measure of a successful incident reporting system is whether the information it yields is used appropriately to improve patient and organization safety.
OBJECTIVES
To systematic review literature to determine incident reporting systems improve patient outcomes and organization outcomes, and to identify successful characteristics of incident reporting system which information it yields is used appropriately to improve patient and organization safety, and to investigate if the incident reporting system can serve as an interface to support the (inform and influence) information flows in the WHO’s Conceptual Framework for the International Classification for Patient Safety.
METHODS
Two bibliography databases, Medline and Embase via OvidSP, were systematically searched using search keywords of ‘incident reporting’, ‘patient / organization outcomes’. Quality appraisal, data extraction were conducted on literature which met the inclusion criteria. Narrative synthesis was conducted.
RESULTS
A total of 584 citations were initially identified and 6 studies were finally included in this systematic review. The methodological quality of the 6 included studies was generally average to poor. The 6 included studies could be classified into 3 groups by research question and intervention strategies examined 1) case series on incident reporting system; 2) comparison study on two main streams of incident reporting systems: routine incident reporting system versus structured case note / chart review; and 3) review of incident reporting systems. Successful characteristics of incident reporting system identified including confidential, non-punitive, expert analysis, system-oriented, responsive, standardized taxonomy coding, clarified and unified concepts of incident reporting system, voluntary reporting, facilitation reporting, proper training and health informatics infrastructure support. Quantitative and qualitative evidences were identified that incident reporting system could serve as an interface to support inform and influence types of information flows in the WHO’s Conceptual Framework for the ICPS. However, no evidence could be found that incident reporting systems could directly improve patient outcomes and organization outcomes.
CONCLUSION
This systematic review found no evidence that incident reporting systems could directly improve patient outcomes and organization outcomes, but the systems could serve as an interface to support information flows in the WHO’s Conceptual Framework for the ICPS. Successful characteristics of an incident reporting system were identified coherent to the WHO’s recommendations. Future studies can further examine the causation relationship between incident reporting systems and the process components by applying the Donabedian’s structure-process-outcome model. / published_or_final_version / Public Health / Master / Master of Public Health
| Identifer | oai:union.ndltd.org:HKU/oai:hub.hku.hk:10722/179922 |
| Date | January 2012 |
| Creators | Mo, Ho-kwan., 毛皓羣. |
| Publisher | The University of Hong Kong (Pokfulam, Hong Kong) |
| Source Sets | Hong Kong University Theses |
| Language | English |
| Detected Language | English |
| Type | PG_Thesis |
| Source | http://hub.hku.hk/bib/B48424936 |
| Rights | The author retains all proprietary rights, (such as patent rights) and the right to use in future works., Creative Commons: Attribution 3.0 Hong Kong License |
| Relation | HKU Theses Online (HKUTO) |
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