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. 2024 Oct 4:26:e48580.
doi: 10.2196/48580.

Patient Safety Incident Reporting and Learning Guidelines Implemented by Health Care Professionals in Specialized Care Units: Scoping Review

Tusiwe Mabel Gqaleni  1 , Sipho Wellington Mkhize  1 , Geldine Chironda  1
Affiliations

Patient Safety Incident Reporting and Learning Guidelines Implemented by Health Care Professionals in Specialized Care Units: Scoping Review

Tusiwe Mabel Gqaleni et al. J Med Internet Res. .

Abstract

Background: Implementing Patient Safety Incident Reporting and Learning (PSIRL) guidelines is critical in guiding clinical practice and improving clinical outcomes in specialized care units (SCUs). There is limited research on the evidence of the implemented PSIRL guidelines in SCUs at the global level.

Objective: This review aims to map the evidence of PSIRL guidelines implemented by health care professionals in specialized care units globally.

Methods: A scoping review methodology, according to Joanna Briggs Institute, was adopted. The eligibility criteria were guided by the Population, Concept, and Context (PCC) framework, with the Population including health care professionals, the Concept including PSIRL guidelines, and the Context including specialized units globally. Papers written in English were searched from relevant databases and search engines. The PRISMA-ScR (Preferred Reporting Items for Scoping Reviews and Meta-Analyses extension for Scoping Reviews) checklist for used.

Results: The 13 selected studies were published from 2003 to 2023. Most articles are from the Netherlands and Switzerland (n=3), followed by South Africa (n=2). The nature of implemented PSIRL guidelines was computer-based (n=11) and paper-based incident reporting (n=2). The reporting system was intended for all the health care professionals within the specialized units, focusing on patients, staff members, and families. The outcomes of implemented incident reporting guidelines were positive, as evidenced by improved reporting of incidents, including medication errors (n=8) and decreased rate of incidents and errors (n=4). Furthermore, 1 study showed no change (n=1) in implementing the incident reporting guidelines.

Conclusions: The implementation of reporting of patient safety incidents (PSIs) in specialized units started to be reported around 2002; however, the frequency of yearly publications remains very low. Although some specialized units are still using multifaceted interventions and paper reporting systems in reporting PSIs, the implementation of electronic and computer-based reporting systems is gaining momentum. The effective implementation of an electronic-based reporting system should extend into other units beyond critical care units, as it increases the reporting of PSIs, reducing time to make an informed reporting of PSIs and immediate accessibility to information when needed for analysis. The evidence on the implementation of PSI reporting guidelines in SCUs comes from 5 different continents (Asia, Africa, Australia, Europe, and North America). However, the number identified for certain countries within each continent is very minimal.

Keywords: ICU; adverse events; clinical practice; critical care units; guidelines; harm; healthcare professional; implementation guidelines; implementation practices; intensive care units; intervention strategies; near misses; patient safety; patient safety incidents; reporting guidelines; specialized care unit.

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Conflict of interest statement

Conflicts of Interest: None declared.

Figures

Figure 1
Figure 1
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram.
See this image and copyright information in PMC

References

    1. World Health Organization National guideline for patient safety incident reporting and learning in the public health sector of South Africa. [2024-09-05]. https://test.idealhealthfacility.org.za/App/Document/Download/53 .
    1. World Alliance For Patient Safety Drafting Group. Sherman H, Castro G, Fletcher M, World Alliance for Patient Safety. Hatlie M, Hibbert P, Jakob R, Koss R, Lewalle P, Loeb J, Perneger T, Runciman W, Thomson R, Van Der Schaaf T, Virtanen M. Towards an international classification for patient safety: the conceptual framework. Int J Qual Health Care. 2009;21(1):2–8. doi: 10.1093/intqhc/mzn054. https://europepmc.org/abstract/MED/19147595 mzn054 - DOI - PMC - PubMed
    1. Runciman W, Hibbert P, Thomson R, Van Der Schaaf T, Sherman H, Lewalle P. Towards an international classification for patient safety: key concepts and terms. Int J Qual Health Care. 2009;21(1):18–26. doi: 10.1093/intqhc/mzn057. https://europepmc.org/abstract/MED/19147597 mzn057 - DOI - PMC - PubMed
    1. Ahmed AH, Thongprayoon C, Schenck LA, Malinchoc M, Konvalinová A, Keegan MT, Gajic O, Pickering BW. Adverse in-hospital events are associated with increased in-hospital mortality and length of stay in patients with or at risk of acute respiratory distress syndrome. Mayo Clin Proc. 2015;90(3):321–328. doi: 10.1016/j.mayocp.2014.12.015.S0025-6196(14)01138-0 - DOI - PubMed
    1. Henneman EA, Gawlinski A, Giuliano KK. Surveillance: a strategy for improving patient safety in acute and critical care units. Critical Care Nurse. 2012;32(2):e9–e18. doi: 10.4037/ccn2012166. https://doi.org - DOI - PubMed

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