Incident Reporting Systems: How did we get here and where should we go? a narrative review
Abstract
Since the authoring of the seminal report by the Institute of Medicine (IOM) “To Err is Human: Building a Safer Health System” in 2000, there has been an increased focus on patient safety and the responsibility born by the healthcare system to reduce what are known as adverse events (AE). One of the recommendations of the IOM report was the establishment and development of Incident Reporting System (IRS) that would track AE resulting in serious injury and death. The Joint Commission in the USA similarly requires all hospitals have and use an IRS. The objective of this review is to explore barriers and feature of IRS and patient safety.
1. Institute of Medicine (US) Committee on Quality of Health Care in America, Kohn LT, Corrigan JM, Donaldson MS (Eds.). (2000). To Err is Human: Building a Safer Health System. National Academies Press (US).
2. Brennan T, Leape L, Laird N, Hebert L, Localio A, Lawthers A, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Qual Saf Health Care. 2004;13(2):145-52.
3. Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care 2009;21(1):18-26.
4. Fitzgerald EM, Cawley D, Rowan NJ. Irish staff nurses perceptions of clinical incident reporting. Int J Nurs Didact. 2013;3(2):14-21.
5. Larizgoitia I, Bouesseau MC, Kelley E. WHO Efforts to Promote Reporting of Adverse Events and Global Learning. J Public Health Res. 2013;2(3):e29.
6. McElroy LM, Woods DM, Yanes AF, Skaro AI, Daud A, Curtis, T, et al. Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population. Int J Qual Health Care. 2016;28(2):166-74.
7. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff (Millwood). 2011;30(4):596-603.
8. Latif A, Halim MS, Pronovost PJ. Eliminating Infections in the ICU: CLABSI. Curr Infect Dis Rep. 2015;17(7):491.
9. Rosenthal MB. Nonpayment for performance? Medicare's new reimbursement rule. N Engl J Med. 2007;357(16):1573-5.
10. Declines in Hospital-Acquired Conditions. Content last reviewed July 2020. Agency for Healthcare Research and Quality, Rockville, MD. [Available from: https://www.ahrq.gov/data/infographics/hac-rates_2019.html].
11. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-23.
12. Fassett WE. Patient Safety and Quality Improvement Act of 2005. Ann Pharmacother. 2006;40(5):917-24.
13. World Health Organization. Patient safety. Global action on patient safety. Report by the Director-General. 2018. Accessed June 15, 2022. [Available at: https://apps.who.int/gb/ebwha/pdf_files/EB144/B144_29-en.pdf].
14. European Commission. Key findings and recommendations on reporting and learning systems for patient safety incidents across Europe. 2014. Accessed June 15, 2022. [Available at: http://buonepratiche.agenas.it/documents/More/8.pdf].
15. Doupi P. National reporting systems for patient safety incidents: a review of the situation in Europe. Accessed June 15, 2022. [Available at: https://thl.fi/documents/10531/104907/Report%202009%2013.pdf].
16. Agency for Healthcare Research and Quality. Common formats. 2016. Accessed June 15, 2022. [Available at: https://pso.ahrq.gov/common].
17. Elkin PL, Johnson HC, Callahan MR, Classen DC. Improving patient safety reporting with the common formats: Common data representation for Patient Safety Organizations. J Biomed Inform. 2016;64:116-21.
18. National Quality Forum. Serious reportable events in healthcare – 2011 update: a consensus report. 2011. Accessed June 15, 2022. [Available at: https://www.doh.wa.gov/Portals/1/Documents/2900/NQF2011Update.pdf].
19. Hegarty J, Flaherty SJ, Saab MM, Goodwin J, Walshe N, Wills T, et al. An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review. J Patient Saf. 2021;17(8):e1247-54.
20. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32.
21. Health Quality Ontario. Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis. Ont Health Technol Assess Ser. 2017;17(3):1-23.
22. Donnelly P. Improving reporting of critical incidents through education and involvement. BMJ Qual Improv Rep. 2015;4(1):u206996.w3776.
23. Tsang C, Palmer W, Bottle A, Majeed A, Aylin P. A review of patient safety measures based on routinely collected hospital data. Am J Med Qual. 2012;27(2):154-69.
24. Henneman EA, Gawlinski A, Blank FS, Henneman PL, Jordan D, McKenzie JB. Strategies used by critical care nurses to identify, interrupt, and correct medical errors. Am J Crit Care. 2010;19(6):500-9.
25. Kreckler S, Catchpole K, McCulloch P, Handa A. Factors influencing incident reporting in surgical care. Qual Saf Health Care. 2009;18(2):116-20.
26. Evans SM, Berry JG, Smith BJ, Esterman A, Selim P, O'Shaughnessy J, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15(1):39-43.
27. Schectman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43.
28. Loren DJ, Garbutt J, Dunagan WC, Bommarito KM, Ebers AG, Levinson W, et al. Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm J Qual Patient Saf. 2010;36(3):101-8.
29. Castel ES, Ginsburg LR, Zaheer S, Tamim H. Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? BMC Health Serv Res. 2015;15:326.
30. Hohenhaus SM. Emergency nursing and medical error--a survey of two states. J Emerg Nurs. 2008;34(1):20-5.
31. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013;2(3):e27.
32. Hsu E, Lin D, Evans SJ, Hamid KS, Frick KD, Yang T, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual. 2014;29(1):13-9.
33. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):69-75.
34. Holden RJ, Karsh BT. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Hum Factors. 2007;49(2):257-76.
35. Flemons WW, McRae G. Reporting, learning and the culture of safety. Healthc Q. 2012;15 Spec No:12-7.
36. Vallejo-Gutiérrez P, Bañeres-Amella J, Sierra E, Casal J, Agra Y. Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP. Rev Calid Asist. 2014;29(2):69-77.
37. Karsh BT, Escoto KH, Beasley JW, Holden RJ. Toward a theoretical approach to medical error reporting system research and design. Appl Ergon. 2006;37(3):283-95.
38. Jeffs L, Law M, Baker GR. Creating reporting and learning cultures in health-care organizations. Can Nurse. 2007;103(3):16-28.
39. Reed S, Arnal D, Frank O, Gomez-Arnau JI, Hansen J, Lester O, et al. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth. 2014;112(3):546-55.
40. Heard, GC, Sanderson PM, Thomas RD. Barriers to adverse event and error reporting in anesthesia. Anesth Analg. 2012;114(3):604-14.
41. Sinclair A, Guérin A, Robin C, Dey P. Investigating the cost and efficiency of incident reporting in a specialist paediatric NHS hospital and impact on patient safety. Eur J Hosp Pharm. 2017;24(2):91-5.
42. Shermock KM, Horn E, Lipsett PA, Pronovost PJ, Dorman T. Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients. Crit Care Med. 2005;33(3):497-503.
43. Maenthaisong R, Chaiyakunapruk N, Thamlikitkul V. Cost-effectiveness analysis of chlorhexidine gluconate compared with povidone-iodine solution for catheter-site care in Siriraj Hospital, Thailand. J Med Assoc Thai. 2006;89 Suppl 5:S94-101.
44. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Sullivan SD, Saint S. Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis. 2003;37(6):764-71.
45. Waters HR, Korn R, Jr Colantuoni E, Berenholtz SM, Goeschel CA, Needham DM, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011;26(5):333-9.
46. Regenbogen SE, Greenberg CC, Resch SC, Kollengode A, Cima RR, Zinner MJ, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
47. Hill J, Treasure T. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients having surgery: summary of NICE guidance. Heart. 2010;96(11):879-82.
48. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu AW, et al. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med. 2003;31(4):1006-11.
49. Stanhope N, Crowley-Murphy M, Vincent C, O'Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5(1):5-12.
50. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007;334(7584):79.
51. Marang-van de Mheen PJ, van Hanegem N, Kievit J. Effectiveness of routine reporting to identify minor and serious adverse outcomes in surgical patients. Qual Saf Health Care. 2005;14(5):378-82.
52. Wagner LM, Capezuti E, Clark PC, Parmelee PA, Ouslander JG. Use of a falls incident reporting system to improve care process documentation in nursing homes. Qual Saf Health Care. 2008;17(2):104-8.
53. Boyle TA, Scobie AC, MacKinnon NJ, Mahaffey T. Implications of process characteristics on quality-related event reporting in community pharmacy. Res Social Adm Pharm. 2012;8(1):76-86.
54. Stavropoulou C, Doherty C, Tosey P. How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. Milbank Q. 2015;93(4):826-66.
55. Zhan C, Smith SR, Keyes MA, Hicks RW, Cousins DD, Clancy CM. How useful are voluntary medication error reports? The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;34(1):36-45.
56. Wysowski DK, Swartz L. Adverse drug event surveillance and drug withdrawals in the United States, 1969-2002: the importance of reporting suspected reactions. Arch Intern Med. 2005;165(12):1363-9.
57. Kalapurakal JA, Zafirovski A, Smith J, Fisher P, Sathiaseelan V, et al. A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. Int J Radiat Oncol Biol Phys. 2013;86(2):241-8.
58. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6):492-7.
59. Callum JL, Kaplan HS, Merkley LL, Pinkerton PH, Rabin Fastman B, Romans RA, et al. Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion. 2001;41(10):1204-11.
60. Askeland RW, McGrane S, Levitt JS, Dane SK, Greene DL, Vandeberg JA, et al. Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. Transfusion. 2008:48(7):1308-17.
61. Jayaram G, Doyle D, Steinwachs D, Samuels J. Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism. J Psychiatr Pract. 2011;17(2):81-8.
2. Brennan T, Leape L, Laird N, Hebert L, Localio A, Lawthers A, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. Qual Saf Health Care. 2004;13(2):145-52.
3. Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an International Classification for Patient Safety: key concepts and terms. Int J Qual Health Care 2009;21(1):18-26.
4. Fitzgerald EM, Cawley D, Rowan NJ. Irish staff nurses perceptions of clinical incident reporting. Int J Nurs Didact. 2013;3(2):14-21.
5. Larizgoitia I, Bouesseau MC, Kelley E. WHO Efforts to Promote Reporting of Adverse Events and Global Learning. J Public Health Res. 2013;2(3):e29.
6. McElroy LM, Woods DM, Yanes AF, Skaro AI, Daud A, Curtis, T, et al. Applying the WHO conceptual framework for the International Classification for Patient Safety to a surgical population. Int J Qual Health Care. 2016;28(2):166-74.
7. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 billion problem: the annual cost of measurable medical errors. Health Aff (Millwood). 2011;30(4):596-603.
8. Latif A, Halim MS, Pronovost PJ. Eliminating Infections in the ICU: CLABSI. Curr Infect Dis Rep. 2015;17(7):491.
9. Rosenthal MB. Nonpayment for performance? Medicare's new reimbursement rule. N Engl J Med. 2007;357(16):1573-5.
10. Declines in Hospital-Acquired Conditions. Content last reviewed July 2020. Agency for Healthcare Research and Quality, Rockville, MD. [Available from: https://www.ahrq.gov/data/infographics/hac-rates_2019.html].
11. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care. 2008;17(3):216-23.
12. Fassett WE. Patient Safety and Quality Improvement Act of 2005. Ann Pharmacother. 2006;40(5):917-24.
13. World Health Organization. Patient safety. Global action on patient safety. Report by the Director-General. 2018. Accessed June 15, 2022. [Available at: https://apps.who.int/gb/ebwha/pdf_files/EB144/B144_29-en.pdf].
14. European Commission. Key findings and recommendations on reporting and learning systems for patient safety incidents across Europe. 2014. Accessed June 15, 2022. [Available at: http://buonepratiche.agenas.it/documents/More/8.pdf].
15. Doupi P. National reporting systems for patient safety incidents: a review of the situation in Europe. Accessed June 15, 2022. [Available at: https://thl.fi/documents/10531/104907/Report%202009%2013.pdf].
16. Agency for Healthcare Research and Quality. Common formats. 2016. Accessed June 15, 2022. [Available at: https://pso.ahrq.gov/common].
17. Elkin PL, Johnson HC, Callahan MR, Classen DC. Improving patient safety reporting with the common formats: Common data representation for Patient Safety Organizations. J Biomed Inform. 2016;64:116-21.
18. National Quality Forum. Serious reportable events in healthcare – 2011 update: a consensus report. 2011. Accessed June 15, 2022. [Available at: https://www.doh.wa.gov/Portals/1/Documents/2900/NQF2011Update.pdf].
19. Hegarty J, Flaherty SJ, Saab MM, Goodwin J, Walshe N, Wills T, et al. An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review. J Patient Saf. 2021;17(8):e1247-54.
20. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725-32.
21. Health Quality Ontario. Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis. Ont Health Technol Assess Ser. 2017;17(3):1-23.
22. Donnelly P. Improving reporting of critical incidents through education and involvement. BMJ Qual Improv Rep. 2015;4(1):u206996.w3776.
23. Tsang C, Palmer W, Bottle A, Majeed A, Aylin P. A review of patient safety measures based on routinely collected hospital data. Am J Med Qual. 2012;27(2):154-69.
24. Henneman EA, Gawlinski A, Blank FS, Henneman PL, Jordan D, McKenzie JB. Strategies used by critical care nurses to identify, interrupt, and correct medical errors. Am J Crit Care. 2010;19(6):500-9.
25. Kreckler S, Catchpole K, McCulloch P, Handa A. Factors influencing incident reporting in surgical care. Qual Saf Health Care. 2009;18(2):116-20.
26. Evans SM, Berry JG, Smith BJ, Esterman A, Selim P, O'Shaughnessy J, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care. 2006;15(1):39-43.
27. Schectman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf. 2006;32(6):337-43.
28. Loren DJ, Garbutt J, Dunagan WC, Bommarito KM, Ebers AG, Levinson W, et al. Risk managers, physicians, and disclosure of harmful medical errors. Jt Comm J Qual Patient Saf. 2010;36(3):101-8.
29. Castel ES, Ginsburg LR, Zaheer S, Tamim H. Understanding nurses' and physicians' fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? BMC Health Serv Res. 2015;15:326.
30. Hohenhaus SM. Emergency nursing and medical error--a survey of two states. J Emerg Nurs. 2008;34(1):20-5.
31. Pham JC, Girard T, Pronovost PJ. What to do with healthcare incident reporting systems. J Public Health Res. 2013;2(3):e27.
32. Hsu E, Lin D, Evans SJ, Hamid KS, Frick KD, Yang T, et al. Doing well by doing good: assessing the cost savings of an intervention to reduce central line-associated bloodstream infections in a Hawaii hospital. Am J Med Qual. 2014;29(1):13-9.
33. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):69-75.
34. Holden RJ, Karsh BT. A review of medical error reporting system design considerations and a proposed cross-level systems research framework. Hum Factors. 2007;49(2):257-76.
35. Flemons WW, McRae G. Reporting, learning and the culture of safety. Healthc Q. 2012;15 Spec No:12-7.
36. Vallejo-Gutiérrez P, Bañeres-Amella J, Sierra E, Casal J, Agra Y. Lessons learnt from the development of the Patient Safety Incidents Reporting an Learning System for the Spanish National Health System: SiNASP. Rev Calid Asist. 2014;29(2):69-77.
37. Karsh BT, Escoto KH, Beasley JW, Holden RJ. Toward a theoretical approach to medical error reporting system research and design. Appl Ergon. 2006;37(3):283-95.
38. Jeffs L, Law M, Baker GR. Creating reporting and learning cultures in health-care organizations. Can Nurse. 2007;103(3):16-28.
39. Reed S, Arnal D, Frank O, Gomez-Arnau JI, Hansen J, Lester O, et al. National critical incident reporting systems relevant to anaesthesia: a European survey. Br J Anaesth. 2014;112(3):546-55.
40. Heard, GC, Sanderson PM, Thomas RD. Barriers to adverse event and error reporting in anesthesia. Anesth Analg. 2012;114(3):604-14.
41. Sinclair A, Guérin A, Robin C, Dey P. Investigating the cost and efficiency of incident reporting in a specialist paediatric NHS hospital and impact on patient safety. Eur J Hosp Pharm. 2017;24(2):91-5.
42. Shermock KM, Horn E, Lipsett PA, Pronovost PJ, Dorman T. Number needed to treat and cost of recombinant human erythropoietin to avoid one transfusion-related adverse event in critically ill patients. Crit Care Med. 2005;33(3):497-503.
43. Maenthaisong R, Chaiyakunapruk N, Thamlikitkul V. Cost-effectiveness analysis of chlorhexidine gluconate compared with povidone-iodine solution for catheter-site care in Siriraj Hospital, Thailand. J Med Assoc Thai. 2006;89 Suppl 5:S94-101.
44. Chaiyakunapruk N, Veenstra DL, Lipsky BA, Sullivan SD, Saint S. Vascular catheter site care: the clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis. 2003;37(6):764-71.
45. Waters HR, Korn R, Jr Colantuoni E, Berenholtz SM, Goeschel CA, Needham DM, et al. The business case for quality: economic analysis of the Michigan Keystone Patient Safety Program in ICUs. Am J Med Qual. 2011;26(5):333-9.
46. Regenbogen SE, Greenberg CC, Resch SC, Kollengode A, Cima RR, Zinner MJ, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-35.
47. Hill J, Treasure T. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients having surgery: summary of NICE guidance. Heart. 2010;96(11):879-82.
48. Beckmann U, Bohringer C, Carless R, Gillies DM, Runciman WB, Wu AW, et al. Evaluation of two methods for quality improvement in intensive care: facilitated incident monitoring and retrospective medical chart review. Crit Care Med. 2003;31(4):1006-11.
49. Stanhope N, Crowley-Murphy M, Vincent C, O'Connor AM, Taylor-Adams SE. An evaluation of adverse incident reporting. J Eval Clin Pract. 1999;5(1):5-12.
50. Sari AB, Sheldon TA, Cracknell A, Turnbull A. Sensitivity of routine system for reporting patient safety incidents in an NHS hospital: retrospective patient case note review. BMJ. 2007;334(7584):79.
51. Marang-van de Mheen PJ, van Hanegem N, Kievit J. Effectiveness of routine reporting to identify minor and serious adverse outcomes in surgical patients. Qual Saf Health Care. 2005;14(5):378-82.
52. Wagner LM, Capezuti E, Clark PC, Parmelee PA, Ouslander JG. Use of a falls incident reporting system to improve care process documentation in nursing homes. Qual Saf Health Care. 2008;17(2):104-8.
53. Boyle TA, Scobie AC, MacKinnon NJ, Mahaffey T. Implications of process characteristics on quality-related event reporting in community pharmacy. Res Social Adm Pharm. 2012;8(1):76-86.
54. Stavropoulou C, Doherty C, Tosey P. How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review. Milbank Q. 2015;93(4):826-66.
55. Zhan C, Smith SR, Keyes MA, Hicks RW, Cousins DD, Clancy CM. How useful are voluntary medication error reports? The case of warfarin-related medication errors. Jt Comm J Qual Patient Saf. 2008;34(1):36-45.
56. Wysowski DK, Swartz L. Adverse drug event surveillance and drug withdrawals in the United States, 1969-2002: the importance of reporting suspected reactions. Arch Intern Med. 2005;165(12):1363-9.
57. Kalapurakal JA, Zafirovski A, Smith J, Fisher P, Sathiaseelan V, et al. A comprehensive quality assurance program for personnel and procedures in radiation oncology: value of voluntary error reporting and checklists. Int J Radiat Oncol Biol Phys. 2013;86(2):241-8.
58. Ross LM, Wallace J, Paton JY. Medication errors in a paediatric teaching hospital in the UK: five years operational experience. Arch Dis Child. 2000;83(6):492-7.
59. Callum JL, Kaplan HS, Merkley LL, Pinkerton PH, Rabin Fastman B, Romans RA, et al. Reporting of near-miss events for transfusion medicine: improving transfusion safety. Transfusion. 2001;41(10):1204-11.
60. Askeland RW, McGrane S, Levitt JS, Dane SK, Greene DL, Vandeberg JA, et al. Improving transfusion safety: implementation of a comprehensive computerized bar code-based tracking system for detecting and preventing errors. Transfusion. 2008:48(7):1308-17.
61. Jayaram G, Doyle D, Steinwachs D, Samuels J. Identifying and reducing medication errors in psychiatry: creating a culture of safety through the use of an adverse event reporting mechanism. J Psychiatr Pract. 2011;17(2):81-8.
| Files | ||
| Issue | Vol 6 No 4 (2022): Autumn (October) | |
| Section | Review article | |
| DOI | 10.18502/fem.v6i4.10441 | |
| Keywords | ||
| Adverse Events Incident Reporting System Patient Safety Risk Management | ||
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How to Cite
1.
David Kao K, Ahmed S, Pyala R, Alsabri M. Incident Reporting Systems: How did we get here and where should we go? a narrative review. Front Emerg Med. 2022;6(4):e54.
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