Interorganisational Patient Safety Incident Reports: An Analytical Perspective.
Jaana Tuppurainen, Hannele Turunen, Kaisa Haatainen
PMID 42028670WHAT IT FOUND
Interorganisational patient safety incidents were mostly about information flow, medication and transfer communication.
Most were assessed as low or insignificant risk. Nurses reported most of them. Reported fixes were usually discussion and reminders, with few detailed plans for changing practice.
Key findings
01Most interorganisational patient safety incidents concerned information flow or management (57%), followed by drug and fluid therapy, blood transfusion, and contrast medium or marker (17%).
02Registered nurses reported 59% of interorganisational patient safety incidents, physicians 20%, and other stakeholders 21%.
03The most common proposed preventive measure was providing information and discussing the event (75%, n = 924), but only 11% (n = 139) described a development measure in response to an open question.
STILL TO COME
How it was doneWhat they foundWhat it means for RNs
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What it does not show
The incident reports are the reporters' own view and assessment, and the reporting system data were not validated, so the descriptions may not be reliable. Risk was assessed by the line manager of the receiving unit, and 8% of reports had no risk category, so severity may be inconsistent. Serious incidents may not appear in this voluntary electronic system because severe incidents are reported separately by law. Harm to the patient was unknown or unreported in 32% of reports, so the real impact on patients is incomplete. The detailed development measures came from only 139 open-field texts, not all 1225 reports. Patients' own perceptions of the incidents were not studied. The data did not show how organisations learned from the development measures or whether the measures were effective.
Declared interests
The authors state they have nothing to declare.
The easy way to misread this
Do not conclude that patient transfers are safe because no report was in the serious risk category. Serious incidents may be reported separately by law, 8% of reports had no risk category, and harm was unknown in 32%.