A web-based incident reporting system : a two years’experience in an Italian research and teaching hospital
Articolo
Data di Pubblicazione:
2014
Citazione:
A web-based incident reporting system : a two years’experience in an Italian research and teaching hospital / A. Bodina, A. Demarchi, S. Castaldi. - In: ANNALI DI IGIENE MEDICINA PREVENTIVA E DI COMUNITÀ. - ISSN 1120-9135. - 26:3(2014), pp. 219-225. [10.7416/ai.2014.1980]
Abstract:
Background. A web-based incident reporting system (IRS) is a tool allowing healthcare workers to voluntary
and anonymously report adverse events/near misses. In 2010, this system was introduced in a research and
teaching hospital in metropolitan area in the North part of Italy, in order to detect errors and to learn from
failures in care delivery. The aim of this paper is to assess whether and how IRS has proved to be a valuable
tool to manage clinical risk and improve healthcare quality.
Materials and Methods. Adverse events are reported anonymously by staff members with the use of an
online template form available in the hospital intranet. We retrospectively reviewed the recorded data for
each incident/near miss reported between January 2011 and December 2012.
Results. The number of reported incidents/near misses was 521 in 2011 and 442 in 2012. In the two years
the admissions were 36.974 and 36.107 respectively. We noticed that nursing staff made more use of IRS
and that reported errors were basically related to prescription and administration of medications.
Conclusions. Much international literature reports that adverse events and near misses are 10% of
admissions. Our data are far from that number, thus meaning that a failure in reporting adverse events
exists. This consideration, together with the high number of near misses in comparison with occurred
errors, leads us to speculate that adverse events with serious consequences for patients are marginally
reported. Probably the lack of a strong leadership considering IRS as an instrument for improving quality
and operators’ reluctance to overcome the culture of blame may negatively affect IRS.
Tipologia IRIS:
01 - Articolo su periodico
Keywords:
errors ; incident reporting ; quality ; risk management
Elenco autori:
A. Bodina, A. Demarchi, S. Castaldi
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