liu.seSearch for publications in DiVA
Change search
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf
Learning From Incident Reporting?: Analysis of Incidents Resulting in Patient Injuries in a Web-Based System in Swedish Health Care
Region Östergötland, Hälso- och sjukvårdens stab.
Region Östergötland, Hälso- och sjukvårdens stab.
Region Östergötland, Regionledningskontoret, Enheten för folkhälsa.
Linköping University, Department of Health, Medicine and Caring Sciences, Division of Society and Health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Regionledningskontoret, Övr Regionledningskontoret.
Show others and affiliations
2020 (English)In: Journal of patient safety, ISSN 1549-8417, E-ISSN 1549-8425, Vol. 16, no 4, p. 264-268Article in journal (Refereed) Published
Abstract [en]

Objectives Incident reporting (IR) systems have the potential to improve patient safety if they enable learningfrom the reported risks and incidents. The aim of this study was to investigate incidents registered in an IR system in a Swedish county council.

Methods The study was conducted in the County Council of Östergötland, Sweden. Data were retrieved from the IR system, which included 4755 incidents occurring in somatic care that resulted in patient injuries from 2004 to 2012. One hundred correctly classified patient injuries were randomly sampled from 3 injury severity levels: injuries leading to deaths, permanent harm, and temporary harm. Three aspects were analyzed: handling of the incident, causes of the incident, and actions taken to prevent its recurrence.

Results Of the 300 injuries, 79% were handled in the departments where they occurred. The department head decided what actions should be taken to prevent recurrence in response to 95% of the injuries. A total of 448 causes were identified for the injuries; problems associated with procedures, routines, and guidelines were most common. Decisions taken for 80% of the injuries could be classified using the IR system documentation and root cause analysis. The most commonly pursued type of action was change of work routine or guideline.

Conclusions The handling, causes, and actions taken to prevent recurrence were similar for injuries of different severity levels. Various forms of feedback (information, education, and dialogue) were an integral aspect of the IR system. However, this feedback was primarily intradepartmental and did not yield much organizational learning.

Place, publisher, year, edition, pages
Wolters Kluwer, 2020. Vol. 16, no 4, p. 264-268
Keywords [en]
patient safety;incident reporting;feedback;learning
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
URN: urn:nbn:se:liu:diva-154047DOI: 10.1097/PTS.0000000000000343ISI: 000595177300015PubMedID: 29112034OAI: oai:DiVA.org:liu-154047DiVA, id: diva2:1282409
Available from: 2019-01-24 Created: 2019-01-24 Last updated: 2021-05-05Bibliographically approved

Open Access in DiVA

No full text in DiVA

Other links

Publisher's full textPubMed

Authority records

Öhrn, AnnicaSjödahl, RuneNilsen, Per

Search in DiVA

By author/editor
Ahlberg, Eva-LenaElfström, JohanBorgstedt Risberg, MadeleineÖhrn, AnnicaAndersson, ChristerSjödahl, RuneNilsen, Per
By organisation
Hälso- och sjukvårdens stabEnheten för folkhälsaDivision of Society and HealthFaculty of Medicine and Health SciencesÖvr RegionledningskontoretDivision of Surgery, Orthopedics and Oncology
In the same journal
Journal of patient safety
Public Health, Global Health, Social Medicine and Epidemiology

Search outside of DiVA

GoogleGoogle Scholar

doi
pubmed
urn-nbn

Altmetric score

doi
pubmed
urn-nbn
Total: 866 hits
CiteExportLink to record
Permanent link

Direct link
Cite
Citation style
  • apa
  • ieee
  • modern-language-association-8th-edition
  • vancouver
  • oxford
  • Other style
More styles
Language
  • de-DE
  • en-GB
  • en-US
  • fi-FI
  • nn-NO
  • nn-NB
  • sv-SE
  • Other locale
More languages
Output format
  • html
  • text
  • asciidoc
  • rtf