Trends in healthcare incident reporting and relationship to safety and quality data in acute hospitals: Results from the National Reporting and Learning System

Quality and Safety in Health Care

Volumn 18, Issue 1, 2009, Pages 5-10

  Hutchinson, A ^a   Young, T A ^a   Cooper, K L ^a   McIntosh, A ^a   Karnon, J D ^a   Scobie, S ^b   Thomson, R G ^b  

^a UNIVERSITY OF SHEFFIELD   (United Kingdom)

^b NATIONAL PATIENT SAFETY AGENCY   (United Kingdom)

Author keywords

[No Author keywords available]

Indexed keywords

DATA COLLECTION; DATABASES AS TOPIC; ENGLAND; GOVERNMENT AGENCIES; HOSPITALS; QUALITY OF HEALTH CARE; RISK MANAGEMENT; SAFETY MANAGEMENT; STATE MEDICINE; WALES;

EID: 61849101459     PISSN: 14753898     EISSN: 14753901     Source Type: Journal    
DOI: 10.1136/qshc.2007.022400     Document Type: Article

References (28)

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington: National Academy Press, 2000.
2. Department of Health. An organisation with a memory, 2000. http://www.dh.gov. uk/assetRoot/04/08/89/48/04088948.pdf (accessed 20 Nov 2006).
3. Williams SK, Osborn SS. The development of the National Reporting and Learning System in England and Wales, 2001-2005. Med J Aust 2006; 184:65-68S.
4. Spigelman AD, Swan J. Review of the Australian incident monitoring system. ANZ J Surg 2005; 75:657-61.
5. Agency for Healthcare Research and Quality. Patient safety reporting systems factsheet, 2001. http://www.ahrq.gov/qual/taskforce/hhsrepor. htm (accessed 20 Nov 2006).
6. National Patient Safety Agency. National Reporting and Learning System. http://www.npsa.nhs.uk/health/reporting/background (accessed 20 Nov 2006).
7. National Patient Safety Agency. Quarterly National Reporting and Learning System Data Summary, Autumn 2006. http://www.npsa.nhs.uk/site/media/ documents/1953-NRLS-Data.pdf (accessed 20 Nov 2006).
8. World Health Organization. World Alliance for Patient Safety: WHO draft guidelines for adverse event reporting and learning systems, 2005. http://www.who. int/patientsafety/events/05/Reporting-Guidelines.pdf (accessed 20 Nov 2006).
9. Giles S, Fletcher M, Baker M, Thomson R. Incident reporting and analysis. In: Walshe K, Boaden R, eds. Patient safety: research into practice. Buckingham: Open University Press, 2005.
10. Evans SM, Berry JG, Smith BJ, et al. Attitudes and barriers to incident reporting: a collaborative hospital study. Qual Saf Health Care 2006; 15:39-43.
11. Kingston MJ, Evans SM, Smith BJ, et al. Attitudes of doctors and nurses towards incident reporting: a qualitative analysis. Med J Aust 2004; 181:36-9.
12. Schectman JM, Plews-Ogan ML. Physician perception of hospital safety and barriers to incident reporting. Jt Comm J Qual Patient Saf 2006; 32:337-43.
13. Waring JJ. Beyond blame: cultural barriers to medical incident reporting. Soc Sci Med 2005; 60:1927-35.
14. Johnson CW. How will we get the data and what will we do with it then? Issues in the reporting of adverse healthcare events. Qual Saf Health Care 2003; 12(Suppl 2):ii64-7.
15. World Health Organization. World Alliance for Patient Safety: project to develop an international patient safety event classification. http://www.who-ipsec.org (accessed 20 Nov 2006).
16. Department of Health and Health Protection Agency. MRSA surveillance system. http://www.hpa.org.uk/infections/topics-az/hai/mandatory- report-2006.htm (accessed 20 Nov 2006).
17. Medicines and Healthcare Products Regulatory Agency. Medical device reporting system. http://www.mhra.gov.uk/home/idcplg?IdcService=SS-GET- PAGE&nodeId=355 (accessed 20 Nov 2006).
18. Healthcare Commission. NHS staff survey. http://www. healthcarecommission.org.uk/nationalfindings/surveys.cfm (accessed 20 Nov 2006).
19. NHS Litigation Authority. Risk management standards. http://www.nhsla.com/RiskManagement (accessed 20 Nov 2006).
20. Healthcare Commission. Hospital clusters. http://ratings2004. healthcarecommission.org.uk/cluster.asp (accessed 20 Nov 2006).
21. Hospital Episode Statistics Online. Data on hospital providers. http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID= 1937&categoryID=212 (accessed 20 Nov 2006).
22. Dr Foster. The hospital guide: how good is my hospital? 2005. http://www.drfoster.co.uk/hospitalreport/pdfs/howGood.pdf (accessed 20 Nov 2006).
23. Agency for Healthcare Research and Quality. Quality indicators. http://www.qualityindicators.ahrq.gov/psi-overview.htm (accessed 20 Nov 2006).
24. Chatfield C. The analysis of time series: An introduction. London: Chapman & Hall/CRC, 2003.
25. StataCorp. Stata Statistical Software: Release 9.0. College Station: Stata Corporation, 2006.
26. National Patient Safety Agency. Building a memory: preventing harm, reducing risks and improving patient safety: The first report of the National Reporting and Learning System and the Patient Safety Observatory, 2005. http://www.npsa.nhs.uk/site/media/documents/1246-PSO-Report-FINAL.pdf (accessed 17 May 2007).
27. Lilford R, Mohammed MA, Spiegelhalter D, et al. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. Lancet 2004; 363:1147-54.
28. Sexton JB, Helmreich RL, Neilands TB, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res 2006; 6:44.