title: Critical incident reporting systems.
abstract: Approximately 10% of all hospital admissions are complicated by critical incidents in which harm is caused to the patient - this amounts to more than 850,000 incidents annually. Critical incident reporting (CIR) systems refer to the structured reporting, collation and analysis of such incidents. This article describes the attributes required for an effective CIR system. Example neonatal trigger events and a management pathway for handling a critical incident report are described. The benefits and limitations of CIR systems, reactive and prospective approaches to the analysis of actual or potential critical incidents and the assessment of risk are also reviewed. Individual human error is but one contributor in the majority of critical incidents. Recognition of this and the fostering of an organisational culture that views critical incident reports as an opportunity to learn and to improve future patient care is vital if CIR systems are to be effective.
authors.affiliation: Neonatal Intensive Care Unit, Addenbrookes Hospital, Hills Road, Cambridge CB2 2QQ, UK. jag.ahluwalia@addenbrookes.nhs.uk
authors.forename: Jag
authors.initials: J
authors.lastname: Ahluwalia
authors.forename: Lin
authors.initials: L
authors.lastname: Marriott
mesh_terms: D005260:Female; D006751:Hospital Information Systems / Q000458:organization & administration* / Q000592:standards; D006801:Humans; D007049:Iatrogenic Disease; D007231:Infant, Newborn; D019300:Medical Errors; D009359:Neonatology / Q000592:standards*; D010500:Perinatology / Q000592:standards*; D011247:Pregnancy; D011785:Quality Assurance, Health Care; D012308:Risk Management / Q000458:organization & administration* / Q000592:standards; D006113:United Kingdom