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Learning From Incid...
Learning From Incident Reporting? : Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care
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- Ahlberg, Eva-Lena (författare)
- Region Östergötland, Hälso- och sjukvårdens stab
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- Elfström, Johan (författare)
- Region Östergötland, Hälso- och sjukvårdens stab
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- Borgstedt Risberg, Madeleine (författare)
- Region Östergötland, Enheten för folkhälsa
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- Öhrn, Annica, 1960- (författare)
- Linköpings universitet,Avdelningen för samhälle och hälsa,Medicinska fakulteten,Region Östergötland, Övr Regionledningskontoret
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- Andersson, Christer (författare)
- Region Östergötland, Hälso- och sjukvårdens stab
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- Sjödahl, Rune, 1938- (författare)
- Linköpings universitet,Avdelningen för Kirurgi, Ortopedi och Onkologi,Medicinska fakulteten,Region Östergötland, Hälso- och sjukvårdens stab
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- Nilsen, Per, 1960- (författare)
- Linköpings universitet,Avdelningen för samhälle och hälsa,Medicinska fakulteten
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(creator_code:org_t)
- Wolters Kluwer, 2020
- 2020
- Engelska.
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Ingår i: Journal of patient safety. - : Wolters Kluwer. - 1549-8417 .- 1549-8425. ; 16:4, s. 264-268
- Relaterad länk:
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https://urn.kb.se/re...
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https://doi.org/10.1...
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Abstract
Ämnesord
Stäng
- Objectives Incident reporting (IR) systems have the potential to improve patient safety if they enable learningfrom the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council.Methods The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence.Results Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline.Conclusions The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.
Ämnesord
- MEDICIN OCH HÄLSOVETENSKAP -- Hälsovetenskap -- Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi (hsv//swe)
- MEDICAL AND HEALTH SCIENCES -- Health Sciences -- Public Health, Global Health, Social Medicine and Epidemiology (hsv//eng)
Nyckelord
- patient safety;incident reporting;feedback;learning
Publikations- och innehållstyp
- ref (ämneskategori)
- art (ämneskategori)
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