Objectives: The purpose of this paper is to discuss the current challenges to using patient safety reporting systems to improve patient safety and present a conceptual model to support the use of reporting and analysis to help guide patient safety improvements. Methods: This research involves an analysis of the methodologies being employed to use medical incident reports to improve patient safety. Areas discussed are risk analysis, incident reporting contributions to risk measures, event taxonomies and process models for health care procedures. Results: A conceptual model for using patient safety reporting systems to improve safety is proposed. It is a comprehensive approach and includes 4 major elements: (1) recognition and reporting of the event, (2) event analysis, (3) analysis of results produced and (4) process changes developed and implemented. A central theme for this model is education and learning to engage staff and organizations and affect behavioral change. Conclusions: Patient safety reporting systems are widely recommended as a strategy to address the important problem of patient safety. In general, most efforts have focused on developing reporting systems and collecting incident data. We are not faced with deciding how best to analyze and report information back to stakeholders and evaluate whether safety has improved. We outline a comprehensive conceptual model to help realize the full potential of reporting systems in improving patient safety.
Revised: July 22, 2010 |
Published: March 23, 2007
Citation
Pronovost P.J., C.G. Holzmueller, J. Young, P.D. Whitney, A.W. Wu, D.A. Thompson, and L.H. Lubomski, et al. 2007.Using Incident Reporting to Improve Patient Safety: A Conceptual Model.Journal of Patient Safety 3, no. 1:27-33. PNWD-SA-7076.