Strengths and weaknesses of the incident reporting system: An Italian experience. Issue 1 (February 2023)

• Record Type: Journal Article
• Authors: Benevento, Marcello; Nicolì, Simona; Mandarelli, Gabriele; Ferorelli, Davide; Cicolini, Giancarlo; Marrone, Maricla; Dell'Erba, Alessandro; Solarino, Biagio
• Is Part Of: Journal of patient safety and risk management. Volume 28:Issue 1(2023)
• Page Start: 15
• Page End: 20
• Publication Date: 2023-02
• Subjects: Incident reporting -- risk management; Medical jurisprudence -- Great Britain -- Periodicals; Medical personnel -- Malpractice -- Great Britain -- Periodicals; Risk management -- Great Britain -- Periodicals
• DOI: 10.1177/25160435221150568
• Languages: English
• ISSNs: 2516-0435

Abstract

One of the cornerstones for enhancing the patient safety culture is the incident reporting system (IRS). It is a process for detecting, reporting, collecting, and summarizing adverse events (AEs) and near-misses in healthcare, and so it represents a vital tool for clinical risk management. We analyzed the 5-year experience of a third-level hospital's IRSs, showing its trends and highlighting its main strengths and weaknesses. Patients' falls and physical or verbal aggression toward the providers or between patients are the most reported events. Underreporting is the main limitation of the system, especially among nurses. Visible actions, forceful analysis of the reports, operators' education, no-blame culture promotion, and organizational adjustments may improve operators' adherence to IRS. Providers do not willingly inform patients' relatives about fatal incidents. Despite that, the IRS is far from its potential, and the number of data collected has increased.