This document discusses patient safety incident reporting and identifies barriers to reporting. It notes that reporting is important for detecting safety issues but is often limited by lack of feedback and fears of punishment. A study found the major barriers to reporting were lack of feedback, limited reporting methods, and fears of consequences. The document proposes a mobile app to make incident reporting easier, anonymous, and provide real-time feedback to encourage reporting. The app would use data to identify safety issues and measure harm reduction efforts.

1. Hossam Elamir, MSc.HCM, TQMD, MBBCh
Quality & Accreditation Office, MKH
Institute of Leadership, RCSI
Ahmad Mufreh, B.M., B. Ch
Department of Surgery, ADH

2. “To err is human,
to cover up is unforgivable, and
to fail to learn is inexcusable.”
Sir Liam Donaldson

3. The report carried 4 core
messages:
 The magnitude of harm that
results from medical errors is
great
 Errors result largely from
systems failures, not people
failures
 Voluntary and mandatory
reporting programs are
needed

4. Martin A Makary, and Michael Daniel
BMJ 2016;353:bmj.i2139

6. Leape, MD

7.  freedom from accidental or preventable
injuries produced by medical care
Spath, P. (2009). Introduction to Healthcare Quality
Management (Chicago, IL, USA: Health Administration Press)

8.  Reporting of patient safety event is universal
in healthcare and a backbone of efforts to
detect patient safety issues and quality
problems.(1,2)
 Barriers to reporting include lack of feedback
and fear of personal consequences.(3,4)

9.  AHRQ stated that effective event reporting
system should have four key elements,
among which are protection of the reporter
privacy, providing easy accessibility to the
reporting system, and timely dissemination
of outcomes and feedbacks.(1)

10.  In the 750+ bedded general hospital; which is
staffed with more than 3000 employees; the
number of reported incidents was 50-80 reports
per month.
 Majority of reporters are nurses (85 %), while
doctors are the least reporting staff.

11.  Most of the reported incidents are of the “no harm
errors” type. Near misses (good catch) and harmful
incidents are usually not reported
 We distributed 35 “incident collection boxes”
allover the hospital, yet, some locations are still
not covered.

12.  We interviewed 200 staff; equally representing
doctors, nurses, technicians and administrators; to
identify the causes of underreporting.
 Fear of punitive action, lack of feedback and
limited access to the manual reporting form were
the most common discouraging causes for not to
report.

13.  Not easily Accessible
 Environmentally unfriendly (Papers, ink)
 Time & Effort to collect
 Redundancy in efforts (Data Entry by the nurses
instead of the reporter)
 No Feedback due to anonymous reporting and/or
overwhelming workload; If feedback given, it will be in
the last stage.

15.  Opportunity for improvement
 Private Public Partnership
 Multidisciplinary team:
 Clinician as a reporter
 Quality Doctor as a manager
 Senior Programmer

16. User friendly
Accessible
Anonymous & Confidential
Secure, HIPPA compliant
Feedbacks the reporter at different stages
Instant Notification
Permits Easy StatisticalAnalysis and Exports Data
Saves History of Reports
Customizable
Affordable
IntelligentAnalysis Framework

21. User friendly
Accessible
Anonymous & Confidential
Secure, HIPPA compliant
Feedbacks the reporter at different stages
Instant Notification
Permits Easy StatisticalAnalysis and Exports Data
Saves History of Reports
Customizable
Affordable
IntelligentAnalysis Framework
Images and Movies
can be attached too!

22. YAMCOLLC

23. 1. AHRQ. Voluntary Patient Safety Event Reporting (Incident Reporting) |
AHRQ Patient Safety Network [Internet]. 2014 [cited 2016 Apr 10].
Available from:
https://psnet.ahrq.gov/primers/primer/13/voluntarypatientsafetyeventr
eportingincidentreporting
2. Lawton R, Parker D. Barriers to incident reporting in a healthcare
system. Qual Saf Health Care. 2002;11(1):15–8.
3. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents
reduces health care’s ability to quantify and accurately measure harm
reduction. J Patient Saf. 2010 Dec;6(4):247–50.
4. Mahajan RP. Critical incident reporting and learning. Br J Anaesth.
2010;105(1):69–75.

24. Dr.HossamElamir
dr_hossam_elamir@hotmail.com
0096565198442
Linkedin:https://kw.linkedin.com/in/hossam-elamir-29697bb2
Dr.AhmadMufreh
Dr.shammar@gmail.com
0096569999126
Linkedin:https://kw.linkedin.com/in/dr-ahmad-m-alshammari-0070b949