Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Controlled Clinical Trial
. 2007 Jun;16(3):169-75.
doi: 10.1136/qshc.2006.019349.

Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals

Sue M Evans  1 , Brian J Smith, Adrian Esterman, William B Runciman, Guy Maddern, Karen Stead, Pam Selim, Jane O'Shaughnessy, Sandy Muecke, Sue Jones
Affiliations
Controlled Clinical Trial

Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals

Sue M Evans et al. Qual Saf Health Care. 2007 Jun.

Abstract

Objectives: To assess the effectiveness of an intervention package comprising intense education, a range of reporting options, changes in report management and enhanced feedback, in order to improve incident-reporting rates and change the types of incidents reported.

Design, setting and participants: Non-equivalent group controlled clinical trial involving medical and nursing staff working in 10 intervention and 10 control units in four major cities and two regional hospitals in South Australia.

Main outcome measures: Comparison of reporting rates by type of unit, profession, location of hospital, type of incident reported and reporting mechanism between baseline and study periods in control and intervention units.

Results: The intervention resulted in significant improvement in reporting in inpatient areas (additional 60.3 reports/10,000 occupied bed days (OBDs); 95% CI 23.8 to 96.8, p<0.001) and in emergency departments (EDs) (additional 39.5 reports/10,000 ED attendances; 95% CI 17.0 to 62.0, p<0.001). More reports were generated (a) by doctors in EDs (additional 9.5 reports/10,000 ED attendances; 95% CI 2.2 to 16.8, p = 0.001); (b) by nurses in inpatient areas (additional 59.0 reports/10,000 OBDs; 95% CI 23.9 to 94.1, p<0.001) and (c) anonymously (additional 20.2 reports/10,000 OBDs and ED attendances combined; 95% CI 12.6 to 27.8, p<0.001). Compared with control units, the study resulted in more documentation, clinical management and aggression-related incidents in intervention units. In intervention units, more reports were submitted on one-page forms than via the call centre (1005 vs 264 reports, respectively).

Conclusions: A greater variety and number of incidents were reported by the intervention units during the study, with improved reporting by doctors from a low baseline. However, there was considerable heterogeneity between reporting rates in different types of units.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None declared.

References

    1. Wilson R M, Runciman W B, Gibberd R W.et al The Quality in Australian Health Care Study. Med J Aust 1995163458–471. - PubMed
    1. Runciman W B, Moller J.Iatrogenic injury in Australia. A report prepared by the Australian Patient Safety Foundation for the National Health Priorities and Quality Branch of the Department of Health and Aged Care of the Commonwealth Government of Australia. Adelaide, South Australia: Australian Patient Safety Foundation, 2001
    1. Australian Council for Safety and Quality in Health Care Maximising national effectiveness to reduce harm and improve care: fifth report to the Australian Health Ministers' Conference. Canberra: Safety and Quality Council, 2004
    1. Expert Group on Learning from Adverse Events in the N H S.An organisation with a memory. London: Stationary Office, 2000
    1. Kohn L T, Corrigan J M, Donaldson M S.To err is human: building a safer health system. Washington, DC: National Academy Press, 20001–16. - PubMed

Publication types

MeSH terms