BACKGROUND Incident reporting is a widely recommended method to measure undesirable events in anaesthesia. Under-utilization is a major weakness of voluntary incident reporting systems. Little is known about factors influencing reporting practices, particularly the clinical environment, anaesthesia team composition, severity of the incident, and perceived risk of litigation. The purpose of this...

To examine the reliability of adverse incident-reporting systems we carried out a retrospective review of the mother and baby case notes from a series of 250 deliveries in each of two London obstetric units. Notes were screened for the presence of adverse incidents defined by lists of incidents to be reported in accordance with unit protocols. We assessed the percentage of adverse incidents rep...

Incident reporting systems help users to provide information about potential safety hazards. They, therefore, represent an important subset of the wider range of applications that support process improvement. The following pages identify a range of novel computational techniques that can be used to address problems of existing reporting systems. In particular, it is argued that computerassisted...

BACKGROUND Incident reporting (IR) in health care has been advocated as a means to improve patient safety. The purpose of IR is to identify safety hazards and develop interventions to mitigate these hazards in order to reduce harm in health care. Using qualitative methods is a way to reveal how IR is used and perceived in health care practice. The aim of the present study was to explore the exp...

BACKGROUND Medical residents are key figures in delivering health care and an important target group for patient safety education. Reporting incidents is an important patient safety domain, as awareness of vulnerabilities could be a starting point for improvements. This study examined effects of patient safety education for residents on knowledge, skills, attitudes, intentions and behavior conc...

BACKGROUND Catastrophic errors in healthcare are rare, yet the consequences are so serious that where possible, special procedures are put in place to prevent them. As systems become safer, it becomes progressively more difficult to detect the remaining vulnerabilities. Using inadvertent intrathecal administration of vinca alkaloids as an example, we investigated whether analysis of incident re...

INTRODUCTION Practitioners frequently encounter safety problems that they themselves can resolve on the spot. We ask: when faced with such a problem, do practitioners fix it in the moment and forget about it, or do they fix it in the moment and report it? We consider factors underlying these two approaches. METHODS We used a qualitative case study design employing in-depth interviews with 40 ...

OBJECTIVE Hospital incident reporting is widely used but has had limited effectiveness for improving patient safety nationally. We describe the process of establishing a multi-institutional safety event reporting system. METHODS A descriptive study in The Pediatric Emergency Care Applied Research Network of 22 hospital emergency departments was performed. An extensive legal analysis addressed...

Prior research examining sexual assault case attrition has focused on the processing of cases across the justice system. Studies have examined arrest decision making and prosecutorial decision making in an attempt to better understand where and when cases drop out of the system. Less explored are police reporting practices during the initial stage of processing for cases in which the officer st...

INTRODUCTION The introduction of health information technology into clinical settings is associated with unintended negative consequences, some with the potential to lead to error and patient harm. As adoption rates soar, the impact of these hazards will increase. OBJECTIVE Over the last decade, unintended consequences have received great attention in the medical informatics literature, and t...