Integrating Incident Data from Five Reporting Systems to Assess Patient Safety: Making Sense of the Elephant

By examining the impact of five reporting systems, incident reporting, patient complaints, risk management, medical malpractice claims, and executive walk rounds, this study was able to determine which patient safety concerns could be identified by each system. Data was collected over a 22-month period at Brigham and Women’s Hospital, with data for malpractice claims collected from 1996-2006 using CRICO’s CMAPS database.

Little overlap was found in the reporting of each of the five systems, but each was found to address specific patient safety concerns that others could not. Communication problems appeared most often in patient complaints and malpractice claims. Malpractice claims saw the most reports in errors in clinical judgment. Walk rounds tended to identify issues with equipment and supplies, while adverse event reporting systems highlighted identification issues, especially mislabeled specimens. This suggests that hospitals should be using a variety of reporting systems to gain the full picture of patient safety issues.

Citation for the Full-text Article

Levtzion-Korach O, Frankel A, Alcalai H, et al. Integrating incident data from five reporting systems to assess patient safety: Making sense of the elephant. Jt Comm J Qual Patient Saf. 2010 Sep; 36(9): 402-410. doi:10.1016/s1553-7250(10)36059-4.