Dossier n. 250/2015 [Abstract] Something went wrong: can we learn from that? Incident reporting in Emilia-Romagna. 2012-2013

Incident reporting is a notification system focusing on safety events and problems, based on the experience of the frontline personnel. Its value lies in a simple assumption: people directly involved in care processes are the best source of knowledge, information and abilities in order to suggest “wise” solutions to understand hazards, near misses and true errors. As a consequence, system changes preventing new or repeated adverse events can be made easier (Wachter, 2012).

With a 2012-2013 update to the previously published report, this volume starts from the commitments made at that time (Mall, Rodella, 2012, p. 115):

• develop a second, more complete and well-structured report, reducing the weight of the results based on the central database and assigning more value to the local experiences from the healthcare organizations, particularly focusing on the learning activities, besides the reporting practices (Chapter 3);
• review and improve methods of analysis, representation and feedback applicable to the incident reporting information basis acquired in recent years by the Emilia-Romagna region, assuming that better reporting at the regional level drives more benefits to local reporting and data utilization;
• reinforcing the role of incident reporting against further research objectives; according to the World Health Organization, latent failures and a poor safety culture with persistent blame-oriented processes, still represent high priorities in patient safety research (WHO, 2012)

First of all, this report is principally aimed to give a feedback on the efforts deployed in order to honor past commitments and critically appraise the recent results, while comparing our regional with the international experiences and tracking the evolution of incident reporting concepts and practices.

Secondly, starting from the experiences of the healthcare organizations, some considerations and hypotheses are proposed for the future, in the context of a system-wide perspective, including the whole set of tools available nowadays to support patient safety strategies and activities.

Chapter 1 introduces the contents of the report, precisely referring to the concluding remarks of the previous volume, published in 2012. In addition, some international experiences are described (Chapter 2), including the preliminary results of the European project “Patient Safety and Quality of Care (PaSQ)” - in which Italy is also involved - in the attempt to highlight possible steps in conceptual evolution and critical appraisal of incident reporting practices.

Chapter 3 accounts for the central part of the volume and offers a comprehensive perspective on the experiences underway in the Emilia-Romagna healthcare organizations. This overview is built both on the information collected through a questionnaire administered in 2013 and periodical reports, from the regional database, returned to the organizations through the same year. A synthetic 2012-2013 regional update is also presented; in this observation time, more than 7000 notifications were reported from public and private organizations, with a substantially stable trend in the most recent years. Just like in 2005-2011, most critical areas are: falls (25%), drugs management (13%), care services, including nursing care (12%) and patient/site/side identification (9%). Approximately two-thirds of the notifications refer to near misses or harmless events, whereas events with serious outcomes account only for a small proportion. Causes are usually multiple, most of the times involving professionals (43%), patients (31%) or the whole care system (26%).

In addition to the general analysis, two in-depth analyses are included:

• the surgical process, with some descriptive examples;
• the drugs management process, with a focus on cancer patients.

The Appendix accounts for the critical review carried out by a regional working group, leading to an operational proposal mainly directed to make the use of the reporting form easier for the people willing to report. This group has now concluded its mandate and the implementation of the suggested modifications to the regional database will hopefully follow.

It is important to remember that incident reporting is not appropriate for epidemiological purposes, therefore collected notifications cannot be considered valid at all to estimate the occurrence of the reported events. As a consequence, incident reporting data should be interpreted with caution, having in mind a clear concept: a high number of notifications (events or near misses) does not imply that a specific healthcare organization or Department is less safe while, conversely, a small number does not necessarily mean lower levels of patient safety. Indeed, in both cases the attitude to report, the quality of the reporting system and the learning capacity of the organization should be taken into account.

Finally, some concluding remarks are proposed for future developments of the incident reporting system in Emilia-Romagna, within a wider set of methods and tools available and appropriate to support the regional commitment to risk management and patient safety in healthcare.