Reducing gaps in incindent reporting: an integrated information system

Abstract

Abstract Background In Hospitals,interventions aimed at identifying adverse events are based on voluntary reporting by health care professionals. We evaluate the incident reporting system in a Private Clinic which provides medical-surgical-rehabilitative health care services both to NHS and Private Patients. Methods A retrospective study was carried out by retrieving reports of adverse events that occurred from January 2011 to December 2015(processing of the years 2016-2020 is ongoing).Data were obtained from various information sources: institutional incident reporting; reports for administrative and insurance purposes; surveillance activities of the health management; organizational environmental reports; tabulations of transfer to the emergency department. Results A total of 306 adverse events were recorded during the study period. The most reported were transfers(51%), followed by falls(31%).Among those reporting adverse events, the main ones were Doctors(44.72%), followed by Nurses(9.15%) and Physical Therapists(1.41%).The institutional incident reporting system detected 42.5% of the adverse events, underestimating at least 57.5%; moreover, only 27.7% of the events were reported in more than one of the above sources.We are now processing the 2016-2020 data,which can be presented at the EPH Conference. Conclusions It is necessary to use several information sources to reconstruct a reliable epidemiology of adverse events in the hospital,in order to structure an effective system of audit and quality improvement. Key messages Only an integrated risk assessment can promote changes in clinical practice. Reducing gaps in reporting tools means increasing the safety, effectiveness and efficiency.