Patient safety incident capture resulting from incident reports: a comparative observational analysis

BMC Emerg Med. 2015 Apr 11:15:6. doi: 10.1186/s12873-015-0032-7.


Background: Patient safety incident (PSI) discovery is an essential component of quality improvement. When submitted, incident reports may provide valuable opportunities for PSI discovery. However, little objective information is available to date to quantify or demonstrate this value. The objective of this investigation was to assess how often Emergency Department (ED) incident reports submitted by different sources led to the discovery of PSIs.

Methods: A standardized peer review process was implemented to evaluate all incident reports submitted to the ED. Findings of the peer review analysis were recorded prospectively in a quality improvement database. A retrospective analysis of the quality improvement database was performed to calculate the PSI capture rates for incident reports submitted by different source groups.

Results: 363 incident reports were analyzed over a period of 18 months; 211 were submitted by healthcare providers (HCPs) and 126 by non-HCPs. PSIs were identified in 108 resulting in an overall capture rate of 31%. HCP-generated reports resulted in a 44% capture rate compared to 10% for non-HCPs (p < 0.001). There was no difference in PSI capture between sub-groups of HCPs and non-HCPs.

Conclusion: HCP-generated ED incident reports were much more likely to capture PSIs than reports submitted by non-HCPs. However, HCP reports still led to PSI discovery less than half the time. Further research is warranted to develop effective strategies to improve the utility of incident reports from both HCPs and non-HCPs.

Publication types

  • Comparative Study
  • Observational Study

MeSH terms

  • Databases, Factual
  • Emergency Service, Hospital / standards*
  • Emergency Service, Hospital / statistics & numerical data
  • Humans
  • Medical Errors / statistics & numerical data*
  • Patient Safety / statistics & numerical data*
  • Quality Assurance, Health Care / methods*
  • Quality Improvement*
  • Retrospective Studies