Implementation of a Quality Incident Review Team: Effects on Reporting and Resolution
Abstract
Background: Incident reporting systems (IRS) are used for gathering data to improve knowledge and decrease errors in the hospital. There is an established need for reporting, with available research focused on patient safety culture, barriers to reporting. Process improvement methods to increase incident reporting, and follow-up for of incidents is lacking in literature.
Method: In April, an Interdisciplinary Quality Incident Review Team (QIRT) was implemented. The QIRT, involved education of staff and managers, incident assignment, and follow-up for resolution. Three measurement times were (1) Baseline (pre-implementation –January through March 2019), (2) 3-month post-implementation data (April through June 2019), and (3) 6-months post-implementation.
Results: Implementation of the QIRT and associated interventions resulted in an increase in overall reporting of patient safety incidents. During the implementation measurement period, there was a 29% increase over the pre-implementation period, and a 37% increase during the post-implementation period. Nursing incidents had the largest decrease in resolution days to an average of 11 in the post-implementation period.
Conclusions: Implementation of the QIRT, increased incident reporting in all areas. Nursing incidents showed the only significant decrease in resolution time. Limitations included involvement of leadership in morning huddles, and knowledge of new leaders in use of the IRS, may have impacted the ability for some managers to complete their incidents.
