Patient safety incident capture resulting from incident reports: a comparative observational analysis

Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this inv...

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Veröffentlicht in:BMC emergency medicine 2015-04, Vol.15 (1), p.6-6, Article 6
Hauptverfasser: Reznek, Martin A, Kotkowski, Kevin A, Arce, Michael W, Jepson, Zachary K, Bird, Steven B, Darling, Chad E
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container_end_page 6
container_issue 1
container_start_page 6
container_title BMC emergency medicine
container_volume 15
creator Reznek, Martin A
Kotkowski, Kevin A
Arce, Michael W
Jepson, Zachary K
Bird, Steven B
Darling, Chad E
description Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs. A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups. 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p 
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When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs. A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups. 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p &lt; 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs. HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. 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When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs. A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups. 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p &lt; 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs. HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. 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subjects Analysis
Comparative analysis
Databases, Factual
Emergency medicine
Emergency Service, Hospital - standards
Emergency Service, Hospital - statistics & numerical data
Evaluation
Health care industry
Humans
Medical Errors - statistics & numerical data
Patient Safety - statistics & numerical data
Quality Assurance, Health Care - methods
Quality control
Quality Improvement
Retrospective Studies
title Patient safety incident capture resulting from incident reports: a comparative observational analysis
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