Dossier n. 231/2012 [Abstract] Incident reporting in Emilia-Romagna: state of the art and future developments

Incident reporting is a notification system developed within high risk organizations and adapted to the health care context, initially used in Australia and subsequently also extended to other Countries.

The tool allows health professionals to describe and report adverse events - defined as any unintended harm caused by the health system rather than by patient’s disease (Brennan et al., 1991) - and so called near misses - defined as “avoided events” related to errors that did not result in injury, illness, or damage, but had the potential to do so (Ministero della salute, 2007).

Information obtained using incident reporting systems enable to identify factors leading to notified events, possible corrections and adjustments already implemented to prevent any recurrence of the same events (Thomas et al., 2011). The main goal of this (and other) spontaneous notification system is to offer the chance to learn from experience and to teach health organizations how to improve.

In the context of a long-standing program of risk management in the health care environment, Emilia-Romagna Region has been promoting for several years the spontaneous notification of events and has created for this purpose an incident reporting regional database.

The Dossier analyzes and presents information and data collected at the regional level in the last seven years (2005-2011); it also represents an important chance to relaunch and renovate a tool that is useful to watch over safety in health organizations.

The first Chapter suggests some hints to correctly interpret data, to give full weight to the tool and to understand its limits. In the following Chapter the history of incident reporting and the first international experiences in the health sector are presented.

A (non systematic) literature review reinforces important aspects (Chapter 3). In particular, international studies highlight that various information sources contribute to monitoring patient’s safety, by recording different events (both for type and for outcome) with very little overlapping of cases. It is thus clear that only an integrated reading of survey systems and a global vision allow to have a complete picture of areas at risk that need improvement interventions.

Chapter 4 briefly describes the various information sources and lists the main reporting system implemented in Italy.

In the following Chapter, the experience of the Emilia-Romagna Region is presented, with over 14,000 notifications from public and private structures. The main critical issues are falls (25%), medication management (13%), events connected to care delivery (12%), identification of patient/seat/side (9%). About two thirds of notifications refer to avoided or harmless events, whereas only a very small proportion of reports refer to events with major outcomes. Causes leading to the events are usually multiple, half of them are active mistakes, followed by organizational errors (26%) and other patient-related aspects (19%).

Some focuses have been developed on specific relevant topics:

• patient’s aggressive behaviour, self-directed or against others, with examples
• events in diagnostic imaging, with results of the experimental implementation of a new notification format in a few Health Trusts
• surgery path
• medication management

A section is dedicated to two Trust experiences, describing the path and difficulties encountered while introducing the spontaneous notification system, as well as the improvement actions implemented and promising ideas to promote a larger sharing of acquired knowledge.

The conclusion (Chapter 6) focuses on original goals and intrinsic limits of incident reporting and proposes some hypothesis for the future work, in particular on criteria and methods of analysis, development of learning opportunities at regional and Trust level as well as communication processes.