University of Surrey

Test tubes in the lab Research in the ATI Dance Research

How effective are incident reporting systems for improving patient safety? A systematic literature review

Stavropoulou, C, Doherty, C and Tosey, P (2015) How effective are incident reporting systems for improving patient safety? A systematic literature review The Milbank Quarterly, 93 (4). pp. 826-866.

[img]
Preview
Text
MQ_pre publication.pdf
Available under License : See the attached licence file.

Download (522kB) | Preview
[img]
Preview
Text (licence)
SRI_deposit_agreement.pdf
Available under License : See the attached licence file.

Download (33kB) | Preview

Abstract

Context: Incident reporting systems (IRSs) are used to gather information on patient safety incidents. However, and despite the financial burden they imply, little is known about their effectiveness. This paper reviews systematically the effectiveness of IRSs as a method of improving patient safety through organizational learning. Method: This systematic literature review identified two groups of studies: a) studies comparing the effectiveness of IRSs relative to other methods of error reporting and b) studies examining the effectiveness of IRSs on settings, structures and outcomes in respect of improvements to patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single loop and double loop learning. Findings: In total, 43 studies were identified. Eight studies compared IRSs with other methods, while 35 explored the effectiveness of IRSs on settings, structures and outcomes. We did not find strong evidence that IRSs perform better than other methods. We found some evidence of single loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence either of improvements to outcomes or of changes to latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double loop learning that is, cultural change or change of mindset. Conclusions: The results indicate IRSs could be more effective if there were explicit criteria for what counts as an incident; they are owned and led by clinical teams rather than centralized hospital departments; and embedded within organizations as part of wider safety programs.

Item Type: Article
Divisions : Faculty of Arts and Social Sciences > Surrey Business School
Authors :
AuthorsEmailORCID
Stavropoulou, CUNSPECIFIEDUNSPECIFIED
Doherty, CUNSPECIFIEDUNSPECIFIED
Tosey, PUNSPECIFIEDUNSPECIFIED
Date : 2 December 2015
Identification Number : 10.1111/1468-0009.12166
Uncontrolled Keywords : Patient safety, Incident reporting systems, organizational learning, single loop learning, double loop learning
Related URLs :
Additional Information : © 2015 The Milbank Memorial Fund. This is the peer reviewed version of the following article: Stavropoulou, C, Doherty, C & Tosey, P 'How effective are incident reporting systems for improving patient safety? A systematic literature review'. Milbank Quarterly, which is published in final form at http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1468-0009.
Depositing User : Symplectic Elements
Date Deposited : 28 Jul 2015 10:55
Last Modified : 02 Dec 2016 02:08
URI: http://epubs.surrey.ac.uk/id/eprint/807941

Actions (login required)

View Item View Item

Downloads

Downloads per month over past year


Information about this web site

© The University of Surrey, Guildford, Surrey, GU2 7XH, United Kingdom.
+44 (0)1483 300800