I. Introduction
Incident Reporting Systems (IRS) are currently one of most prevalent safety improvement strategies in healthcare. However, IRS have proven to be inherently problematic as clinicians and health scientists struggle with issues affecting IRS’ perceived and actual utility. Problems arise due to the fact “sentinel/ seminal/never events/adverse events” (all terms to describe events that should not happen in healthcare) are usually uncommon and difficult to detect. IRS are prone to biases and create high-cost information and are that clinicians, patient safety practitioners and researchers must be aware of when using them to conduct evaluations. , Recent literature suggest patient safety experts recognize that IRS often do not engender in-depth analyses or lead to robust interventions to reduce risk.
II. What is IRS?
IRS, to the article authors, are “a collection of snapshots of hazards, mistakes and system failures occurring in healthcare” The article states organizations have in the past few decades used IRS as “repositories of information about hazards, medical mistakes and systems failures at the local, state or national level.” Specifically, the article attempts to concentrate on to large hospital-based systems or hospital networks (Joint Commission, Medicare, etc.) but also looks at systems in regards to nursing homes, medication safety, vaccine adverse events, and devices-equipment adverse events. (FDA) III. The Three Components Required for a Useful Evaluation Per the authors, three components are necessary to conduct a useful evaluation and then properly evaluate progress in patient safety. They are namely: (A) a sound definition of the event, (B) identification of those at risk for the event, and (C) a standard and the active surveillance system. The components work together to form a patient safety rate from standard indicators that can be created to surveil or closely monitor frequency. Common patient safety rates include rates of incidence, prevalence, error and harm. A. Sound Definition of the Event The authors state a “sound definition of the event” is needed to efficiently evaluated IRS. To further standardize hospital event reporting, AHRQ developed a set of event definitions and incident reporting tools known as the “Common Formats”. The authors felt improvements are difficult to demonstrate without clear definitions and without adequate funding/staffing. To speak to its veracity, a sound definition must have a common, contemporary following and be technically vetted through consensus of professional’s opinions in peer-review journals. For useful evaluation, a sound definition of the event and a counting of its occurrence will make up the numerator of a rate that can be used for comparison across facilities or locations and/or over time. B. Identification of those at risk for the event The total population of those at risk for the event makes up the denominator of patient safety rates which are necessary to compare facilities or locations to evaluate progress in patient safety. Not only does the event definition which makes up the numerator in rates need to be solid, but the denominator for “those at risk for the event” also requires a clear definition. An appropriate denominator might not need to be readily available for calculating a particular type of patient safety rate. (incidence rate, prevalence rate, error rate and harm rate) C. A Standard and Active Surveillance System A standard surveillance systems uses standard, sound definitions of indicators discussed in the “sound definition of the event” paragraph above. An active surveillance system “provides stimulus to healthcare workers in the form …show more content…
Ultimately, the three components must work together to accurately assess patient safety rates during an evaluation to assess frequencies among different locations or points in time. Proper attention to the necessities and limitations that each element pose are explored in the subsequent section. (Section V) At minimum, inferential statistics also require similar requirements to create a sample size for an entire survey sample. A discussion of biostatics theories shedding light on the three necessary components and their limitations can be found in Section VI: Limitations of patient safety rates to compare different facilities?
V. Necessities and Limitations of the Three Components
To begin, each of these components have limitations which may create challenges for the creation of a useful evaluation. These deficiencies must be addressed by the patient safety practitioner or researcher.
A. Necessities and Limitations of “Sound Definitions of an
Incident Reporting Systems (IRS) are currently one of most prevalent safety improvement strategies in healthcare. However, IRS have proven to be inherently problematic as clinicians and health scientists struggle with issues affecting IRS’ perceived and actual utility. Problems arise due to the fact “sentinel/ seminal/never events/adverse events” (all terms to describe events that should not happen in healthcare) are usually uncommon and difficult to detect. IRS are prone to biases and create high-cost information and are that clinicians, patient safety practitioners and researchers must be aware of when using them to conduct evaluations. , Recent literature suggest patient safety experts recognize that IRS often do not engender in-depth analyses or lead to robust interventions to reduce risk.
II. What is IRS?
IRS, to the article authors, are “a collection of snapshots of hazards, mistakes and system failures occurring in healthcare” The article states organizations have in the past few decades used IRS as “repositories of information about hazards, medical mistakes and systems failures at the local, state or national level.” Specifically, the article attempts to concentrate on to large hospital-based systems or hospital networks (Joint Commission, Medicare, etc.) but also looks at systems in regards to nursing homes, medication safety, vaccine adverse events, and devices-equipment adverse events. (FDA) III. The Three Components Required for a Useful Evaluation Per the authors, three components are necessary to conduct a useful evaluation and then properly evaluate progress in patient safety. They are namely: (A) a sound definition of the event, (B) identification of those at risk for the event, and (C) a standard and the active surveillance system. The components work together to form a patient safety rate from standard indicators that can be created to surveil or closely monitor frequency. Common patient safety rates include rates of incidence, prevalence, error and harm. A. Sound Definition of the Event The authors state a “sound definition of the event” is needed to efficiently evaluated IRS. To further standardize hospital event reporting, AHRQ developed a set of event definitions and incident reporting tools known as the “Common Formats”. The authors felt improvements are difficult to demonstrate without clear definitions and without adequate funding/staffing. To speak to its veracity, a sound definition must have a common, contemporary following and be technically vetted through consensus of professional’s opinions in peer-review journals. For useful evaluation, a sound definition of the event and a counting of its occurrence will make up the numerator of a rate that can be used for comparison across facilities or locations and/or over time. B. Identification of those at risk for the event The total population of those at risk for the event makes up the denominator of patient safety rates which are necessary to compare facilities or locations to evaluate progress in patient safety. Not only does the event definition which makes up the numerator in rates need to be solid, but the denominator for “those at risk for the event” also requires a clear definition. An appropriate denominator might not need to be readily available for calculating a particular type of patient safety rate. (incidence rate, prevalence rate, error rate and harm rate) C. A Standard and Active Surveillance System A standard surveillance systems uses standard, sound definitions of indicators discussed in the “sound definition of the event” paragraph above. An active surveillance system “provides stimulus to healthcare workers in the form …show more content…
Ultimately, the three components must work together to accurately assess patient safety rates during an evaluation to assess frequencies among different locations or points in time. Proper attention to the necessities and limitations that each element pose are explored in the subsequent section. (Section V) At minimum, inferential statistics also require similar requirements to create a sample size for an entire survey sample. A discussion of biostatics theories shedding light on the three necessary components and their limitations can be found in Section VI: Limitations of patient safety rates to compare different facilities?
V. Necessities and Limitations of the Three Components
To begin, each of these components have limitations which may create challenges for the creation of a useful evaluation. These deficiencies must be addressed by the patient safety practitioner or researcher.
A. Necessities and Limitations of “Sound Definitions of an