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Making the clinical incident reporting form fit for purpose

Key points

  • We have identified serious flaws in the clinical incident reporting form that healthcare professionals fill out when they realise someone has made a mistake that could affect the safety of a patient.
  • The forms currently used in the NHS do not allow easy and quick reporting at the point of care nor do they support learning from incidents.
  • We have developed an improved form that encourages those filling it out to be more open and honest about mistakes.
  • The changes are based on a combination of past research, the opinion of healthcare professionals and the best features of existing forms.

Reporting Incidents
When healthcare professionals realise a mistake has been made that could affect the safety of a patient they report what happened on a clinical incident reporting form. An investigation then follows to identify: the causes of the incident, whether it might happen again and what can be done to stop it reoccuring. Effective reporting that leads to the organisation as a whole learning from mistakes means that similar errors, that are preventable, will be prevented in the future. A good reporting system should also capture near misses, where incidents were narrowly averted. Doing so helps fix problems before any patient is harmed. The process of reporting also helps people see the bigger picture of where, when and why errors are occurring.

 


"Over the past year, I have been thinking about infusion pumps. What I am learning through CHI+MED is what we have usually put down as user error is not so much that as a design flaw in the device. Since so many devices behave differently, I think it is wrong to classify those as human errors. We need a consistent format. It has led me to a re-evaluation of how we classify these." - UK procurement / clinical engineering hospital stakeholder


 

Are existing reporting forms fit for purpose?
We interviewed professionals, reviewed the existing research in this area and compared the many different forms used in the NHS. As a result we identified several fundamental problems with the reporting forms currently used. For example, the layout and content of the forms is confusing. The terms used to identify what happened do not always make sense, leaving those filling out the forms unsure what they have to report and why.

The forms are also too long leading to the already extremely busy professionals not having time to complete them properly. Another issue is that those who fill out forms get no feedback so have little idea what, if any, changes in practice their report leads to. This makes it hard for them to see the point of reporting, especially as they do not even learn effectively themselves from what happened so cannot  change the way they personally do things to prevent it happening again.

The investigation process should lead to the cause of mistakes being identified and lead to practical changes being implemented to stop it happening again. However, the problems with the forms mean this is not done as well as it could be. Healthcare professionals have confirmed these findings. There are real problems with the reporting forms used and this means people can not learn from and so prevent future error. The current approach also means frontline professionals are being inappropriately blamed for mistakes. The real causes are then not addressed and similar mistakes are likely to happen again. If incidents are not reported then the potential for error increases. This research won best contribution at an international conference on communicating medical error.

A new reporting form
Based on our findings we redesigned the clinical incident reporting form to better fit the needs of both reporter and investigator. We also identified ways in which a computer based form could make the process of reporting and investigating incidents easier. We again worked with the people who report and investigate incidents. We produced a draft of the reporting form, evaluated it and then made improvements, repeating this process,  ultimately leading to a general clinical incident reporting form which is more fit for purpose. It has the potential to now be refined for more specialist incidents.

Based on our recommendations a local health board in Swansea has already made changes to the clinical incident reporting form they use.

References
Lewis, A., & Williams, J. G. (2013). Inefficient clinical incident reporting systems create problems in learning from errors. Talk presented at conference on Communicating Medical Error, Ascona, Switzerland, March. (Abstract only.) pdf (246 KB) abstract