Hospital reports on patient safety incidents can be useful in identifying the contributing factors, but often need more detail
Research Activities, May 2009, No. 345
A new study of the usefulness of hospital reports on patient safety incidents finds that most of the report narratives helped identify factors that contributed to the incident. However, each category of factors (patient, system, and provider factors) was identified in only a minority of the incident reports, and often little detail was provided about provider factors. The researchers conclude that strategies for obtaining narrative descriptions with more details are needed for incident reports to be truly useful in improving patient safety.
At least one contributing factor was identified in 80 percent of reports, with many reports identifying several contributing factors. Patient factors and system factors each showed up in 32 percent of the reports, while provider factors could be noted in 46 percent of the reports. Most of the patient factors were classifiable into subtypes, with the underlying illness being the most common (61 percent of the reports with patient factors). Personnel issues (primarily teamwork and availability of staff) and physical environment issues (unavailability or malfunction of a facility, device, or medicine) were the most common system factors identified. Only slightly more than half of the provider factors could be subclassified; the most common provider factors were slips or lapses, both reflecting unconscious errors.
The researchers examined 2,228 incident reports collected in 2001 by voluntary, but not anonymous, reporting systems at a teaching hospital and an affiliated community hospital in a major metropolitan area. These reports were sampled so that the patients involved would be representative of the 2001 patient population at the two hospitals. Results were adjusted for the number of patients with more than one hospital admission during the calendar year. The study was supported, in part, by the Agency for Healthcare Research and Quality (HS11512).
More details are in "Contributing factors identified by hospital incident report narratives," by Teryl K. Nuckols, M.D., Douglas S. Bell, M.D., Ph.D., Susan M. Paddock, Ph.D., and Lee H. Hilborne, M.D. in the October 2008 issue of Quality and Safety in Health Care 17(5), pp. 368-371.