Patient safety incident reporting is a valuable source of information for providers, patients, and policymakers. It promotes accountability, learning, and improvement of patient safety culture. However, in high-income countries, incident reporting systems fail to realize their potential: reporting rates are as low as five percent, and the information is rarely used for learning and improvement.
A variety of factors account for staffs’ limited reporting, including uncertainty around its impact, fear of blame, and the complexity of reporting interfaces. In low-income countries, incident reporting systems are often completely absent, as the infrastructure required for established reporting solutions is not available.
It is unlikely that these issues will be rectified through incremental changes to existing systems that are already complex, rigid, and difficult to administer, as the United Kingdom National Reporting and Learning System demonstrates. Instead, researchers at the Centre for Health Policy (CHP) based at Imperial College London are testing a new approach to incident reporting through the innovative use of app-based technology.
The app in development—CareReport—is aimed at simplifying reporting by reducing it to the minimum requirements, supporting users to identify safety issues, and prioritizing their resources for quality improvement. The app focuses on minimizing the most common barriers to staff reporting, making it quicker, easier, and more accessible.
Based on our previous analysis of incident reporting systems (in an unpublished work by Stephanie Archer and Louise Hull), researchers at CHP have identified and incorporated into the prototype app four critical principles for innovation:
Inexpensive
An incident reporting platform must be viable in low- and middle-income countries. It should be both inexpensive and functional with only minimal resources. However, best-practice in incident reporting maintains that web-based systems, while more expensive in the short-term, are preferable to paper-based systems. This is because they improve reporting rates, promise more data-security, and yield information that is easier to analyze.
To strike the right balance between affordability and optimal functionality, an incident reporting app should be operable on any computer, smartphone, or tablet. This means hospitals only require one computing device or smart phone to run the app.
The principle of frugality is proving attractive not only to low- and middle-income countries, but also to resource-limited systems in high-income countries such as the British National Health Service (NHS), where it will be part of a trial in a surgical setting. In the NHS, the National Reporting and Learning System has cost taxpayers approximately £221 million (more than $337 million) over the last 13 years.
This does not take into account the complex digital infrastructure, hundreds of computers, and information technology staff within NHS Trusts that are required to access and maintain the system. An inexpensive, app-based reporting tool could represent a financially advantageous alternative in high-income countries as it has a low start-up cost and does not require investment in additional computing infrastructure.
Inviting
A reporting platform needs to incorporate user-centred design to promote uptake and usage amongst staff. Too often, health care innovations fail to draw upon the basic principles of design and usability that are so successful in engaging the user in the technology world.
When CareReport was showcased at the World Innovation Summit for Health in February 2015, clinicians who tried the prototype found that the interface was intuitive, and it took them less than five minutes to report an incident. The app uses simple options for selecting incident types, such as medication errors or assessment incidents.
Each incident type includes clearly stated definitions and examples, all of which are demonstrated components of successful incident reporting systems. For instance, if a doctor is unsure whether something was a medication error, he or she can click on the information button which explains that the term “medication error” encompasses errors in prescribing, order communication, product labelling, and so on.
The clarity and ease of use means that clinicians are not immediately deterred from reporting. Moreover, this has the potential to reduce the lag time between incident occurrence and reporting. Such lags can cause meaningful details to be forgotten.
Most staff will carry the means to report with them at all times, in their pocket, on a device they already interact with multiple times a day. When staff are not frustrated by the reporting process, it not only brings forth a greater number and variety of incidents reported, but it also elevates awareness of patient safety and incidents of harm.
Improvement-oriented
An effective incident reporting system must capture the relevant information for improvement. One of the challenges with current systems is the sheer volume of largely extraneous events or details that are captured. A system should aim to be appropriately parsimonious; it should exclude superfluous information, focusing on the details that are important to providers, patients, and the quality improvement processes.
Moreover, it should capture information in a form that is suitable for large-scale analysis. An app has the potential to depart from traditional free-text systems, which produce statements that are difficult to analyze to identify improvements. App-based technology can provide some free-text to add richness to reports, but at its core uses a multiple-choice approach to facilitate effective analysis and learning.
Impactful
Finally, once a reporting system is mature enough to fulfil the first three requirements, it needs a mechanism to generate feedback and serve as a conduit for patient safety information into a broader strategy for learning and quality improvement. App-based reporting systems can program an immediate feedback loop between the reporter and the individual responsible for managing patient safety within an organization. This ensures the reporter receives a notification when a report is read, followed-up, and acted upon. Such feedback is nearly impossible in a paper reporting system and not typically included in current computer-based systems.
Furthermore, with a multiple-choice system designed for streamlined analysis, the app can generate information for improvement in a timely manner. Current systems use a long series of free-text questions, which contribute to a lag in reporting. When staff delay reporting incidents, the information they give may be fragmented or forgotten, and therefore less useful for driving change.
A focus on the features that generate impact, such as feedback loops and multiple-choice reporting options, means that an app can support the dynamic relationship between patient safety culture and the effectiveness of incident reporting. In other words, evidence of impact will engage staff to report and augment safety culture, and in turn, safety culture will support further investment in incident reporting and create a safe and transparent environment.
The priorities for incident reporting systems have changed over many years since they were first introduced. Reverse engineering of these earlier developed systems is not necessarily the most effective way to promote better use of systems’ data. But learning from their experience to develop new tools with a more advanced understanding is possible.
Information from incident reporting systems is best leveraged when the system is appropriately resourced, galvanizes uptake and usage amongst staff, gathers the most relevant information, and generates feedback for improvement. An app such as CareReport may be the ideal tool to improve incident reporting rates and use of reported information.
The concepts of the app are rooted in rigorous evidence-based research from the experience of other systems, and its model is driven by the feedback of those who will use it the most. The next step is to test its functionality both as an introductory reporting platform in low- and middle-income countries and as an alternate to flawed and cumbersome systems already existing elsewhere.
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