Rates and types of events reported to established incident reporting systems in two US hospitals.
BACKGROUND
US hospitals have had voluntary incident reporting systems for many years, but the effectiveness of these systems is unknown. To facilitate substantial improvements in patient safety, the systems should capture incidents reflecting the spectrum of adverse events that are known to occur in hospitals.


OBJECTIVE
To characterise the incidents from established voluntary hospital reporting systems.


METHODS
Observational study examining about 1000 reports of hospitalised patients at each of two hospitals.


METHODS
16 575 randomly selected patients from an academic and a community hospital in the US in 2001.


METHODS
Rates of incidents reported per hospitalised patient and characteristics of reported incidents.


RESULTS
9% of patients had at least one reported incident; 17 incidents were reported per 1000 patient-days in hospital. Nurses filed 89% of reports, physicians 1.9% and other providers 8.9%. The most common types were medication incidents (29%), falls (14%), operative incidents (15%) and miscellaneous incidents (16%); 59% seemed preventable and preventability was not clear for 32%. Among the potentially preventable incidents, 43% involved nurses, 16% physicians and 19% other types of providers. Qualitative examination of reports indicated that very few involved prescribing errors or high-risk procedures.


CONCLUSIONS
Hospital reporting systems receive many reports, but capture a spectrum of incidents that differs from the adverse events known to occur in hospitals, thereby substantially underdetecting physician incidents, particularly those involving operations, high-risk procedures and prescribing errors. Increasing the reporting of physician incidents will be essential to enhance the effectiveness of hospital reporting systems; therefore, barriers to reporting such incidents must be minimised.
Nuckols
Teryl K
TK
The RAND Corporation, Santa Monica, California, USA. tnuckols@mednet.ucla.edu
Bell
Douglas S
DS
Liu
Honghu
H
Paddock
Susan M
SM
Hilborne
Lee H
LH
D002140:California / Q000453:epidemiology; D019992:Databases as Topic; D030881:Disclosure; D006764:Hospitals, Community / Q000458:organization & administration*; D006785:Hospitals, University / Q000458:organization & administration*; D006801:Humans; D007049:Iatrogenic Disease / Q000453:epidemiology*; D019300:Medical Errors / Q000145:classification / Q000706:statistics & numerical data*; D008505:Medical Staff, Hospital; D009741:Nursing Staff, Hospital; D010043:Outcome and Process Assessment, Health Care; D015397:Program Evaluation; D012308:Risk Management / Q000458:organization & administration / Q000706:statistics & numerical data*; D013597:Systems Analysis