System Safety in Healthcare

Reporting Patient Safety Incidents to Prevent Risk of Harm

Abstract

“Incident reporting” is frequently used as a general term for all voluntary patient safety event reporting systems which rely on those involved in patient care. Initial reports often come from frontline personnel directly involved in an event or the actions leading up to it (e.g., the nurse, pharmacist or physician caring for a patient when an error occurred). Voluntary event reporting is therefore a special form of surveillance for near misses or unsafe conditions that are unlikely to show up in formal surveys [Ref. 1]. The purpose of incident reports is to help identify potential and actual risks and, thus, mitigate hazards. Incident reports also alert risk managers to potential lawsuits. They are generated for at least five types of medical errors: near misses, adverse events, intentional unsafe acts, never events and sentinel events. These events may affect any person on the premises, including patients, employees, physicians, visitors, students or volunteers.