An Interprofessional Quality Incident Review Team: Effects on Reporting and Resolution
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Background: Since the Institute of Medicine's (IOM) report, To Err is Human, there has been increased focus on patient safety, to include use of incident reporting systems for gathering data to improve knowledge and decrease e1rnrs in the hospital. With increased pain and suffering, and cost associated with errors, the justification for these processes are clear. It is known that underreporting of incidents continues. There is a need for reporting systems, with available research focusing on organizational safety culture, ba1Tiers to reporting, and the acceptance of reporting systems in practice. Process improvement methods to increase incident reporting, and resolution of incidents is lacking in literature.
Method: A descriptive repeated measures quality improvement project was undertaken at baseline, 3-months, and 6-months post intervention. Quality metrics were number of patient safety incidents and time to resolution of incident review. The intervention consisted of the development of An Interdisciplinary Quality Incident Review Team (QIRT) at a 147 bed acute care hospital in central Texas, U.S. A. The QIRT process, involved education of staff and managers on the new processes of reporting, evaluating, and completing incident reports.
Results: Implementation of the QIRT process resulted in an increase in overall reporting of patient safety incidents in the categories of medication enors, hospital, nursing, and safety. At 3- months and 6-month post intervention, incident reports increased by 41% (n=21) and 59% (n=30). Hospital Incidents made up greatest increase in rep01i types, while Medication Errors had the fewer rep01is. Time to resolution of Nursing Incident reviews had the largest decrease in resolution time with an average of 11 days. Nursing Incident reporting demonstrated that consistency lead to sustainability over time, as the number of reported incidents continued to increase during the 6-month follow-up.
Conclusions: Implementation of the QIRT, including educational materials and expectations for nursing staff and managers, increased incident reporting in all areas. Education regarding rep01iing, awareness ofrep01ied events, and follow-up from the QIRT were shown to increase reporting across the organization. Nursing incident rep01is were the only category where the time from the incident was reported, to resolution of the incident in the rep01iing system decreased.