A Systematic Review of Incident Reporting Systems Improving Patient Outcomes and Organizational Outcomes

This dissertation, "A Systematic Review of Incident Reporting Systems Improving Patient Outcomes and Organizational Outcomes" by Ho-kwan, Mo, 毛皓羣, was obtained from The University of Hong Kong (Pokfulam, Hong Kong) and is being sold pursuant to Creative Commons: Attribution 3.0 Hong Kong License. The content of this dissertation has not been altered in any way. We have altered the formatting in order to facilitate the ease of printing and reading of the dissertation. All rights not granted by the above license are retained by the author. Abstract: BACKGROUND Patient safety, reducing medical errors and risk management have become a global public health and administrative issue. Population-based studies around the world have alerted high rates of preventable medical errors and deaths. In response, a global effort agreed on a World Health Assembly resolution on patient safety. The World Alliance for Patient Safety guideline and the Conceptual Framework for the International Classification for Patient Safety have been launched by the World Health Organization (WHO) to galvanize and facilitate efforts by all Member States to make health care safer. The guidelines introduced adverse event reporting and focus on reporting and learning to improve the safety of patient care. The WHO suggested a conceptual framework for patient safety providing comprehensive understanding of the domains of patient safety. It represents a continuous learning and improvement cycle emphasizing on proactive (identification of risk, prevention, detection, reduction of risk) and reactive (incident recovery, system resilience) risk management. The ultimate measure of a successful incident reporting system is whether the information it yields is used appropriately to improve patient and organization safety. OBJECTIVES To systematic review literature to determine incident reporting systems improve patient outcomes and organization outcomes, and to identify successful characteristics of incident reporting system which information it yields is used appropriately to improve patient and organization safety, and to investigate if the incident reporting system can serve as an interface to support the (inform and influence) information flows in the WHO's Conceptual Framework for the International Classification for Patient Safety. METHODS Two bibliography databases, Medline and Embase via OvidSP, were systematically searched using search keywords of 'incident reporting', 'patient / organization outcomes'. Quality appraisal, data extraction were conducted on literature which met the inclusion criteria. Narrative synthesis was conducted. RESULTS A total of 584 citations were initially identified and 6 studies were finally included in this systematic review. The methodological quality of the 6 included studies was generally average to poor. The 6 included studies could be classified into 3 groups by research question and intervention strategies examined 1) case series on incident reporting system; 2) comparison study on two main streams of incident reporting systems: routine incident reporting system versus structured case note / chart review; and 3) review of incident reporting systems. Successful characteristics of incident reporting system identified including confidential, non-punitive, expert analysis, system-oriented, responsive, standardized taxonomy coding, clarified and unified concepts of incident reporting system, voluntary reporting, facilitation reporting, proper training and health informatics infrastructure support. Quantitative and qualitative evidences were identified that incident reporting system could serve as an interface to support inform and influence types of information flows in the WHO's Conceptual Framework for the ICPS. However, no evidence could be found that incident reporting systems could directly improve patient outcomes and organization outcomes. CONCLUSION This systematic