Reducing gaps in incindent reporting: an integrated information system

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. [ABSTRACT FROM AUTHOR]