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International recommendations for national patient safety incident reporting systems: An expert Delphi consensus-building process

Title: International recommendations for national patient safety incident reporting systems: An expert Delphi consensus-building process
Authors: Howell, AR
Burns, EM
Hull, L
Sevdalis, N
Mayer, E
Darzi, A
Item Type: Journal Article
Abstract: Background Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care. Objective To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role. Methods After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised. Results Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally. Conclusions We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.
Issue Date: 22-Feb-2016
Date of Acceptance: 24-Jan-2016
URI: http://hdl.handle.net/10044/1/40034
DOI: https://dx.doi.org/10.1136/bmjqs-2015-004456
ISSN: 2044-5415
Publisher: BMJ Publishing Group
Start Page: 150
End Page: 163
Journal / Book Title: BMJ Quality and Safety
Volume: 26
Copyright Statement: Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/
Sponsor/Funder: Imperial College Healthcare NHS Trust
Imperial College Healthcare NHS Trust
National Institute for Health Research (NIHR)
Funder's Grant Number: NRLS2
RDPSC 79560
RDPSC 79560
Keywords: Science & Technology
Life Sciences & Biomedicine
Health Care Sciences & Services
Health Policy & Services
HEALTH-CARE PROFESSIONALS
ADVERSE DRUG EVENTS
INTENSIVE-CARE
QUALITY IMPROVEMENT
LEARNING-SYSTEM
MEDICATION ERROR
AIMS-ICU
SURVEILLANCE
HOSPITALS
LESSONS
Health policy
Incident reporting
Patient safety
Safety culture
Significant event analysis, critical incident review
Publication Status: Published
Appears in Collections:Division of Surgery
Faculty of Medicine



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