Features of incident reports that prompt reviewer feedback and organisational change: A retrospective review

Abstract

Objectives Identifying and recording system failures through incident reporting and enacting appropriate preventative change improves patient outcomes. This study identified the characteristics of a hospital incident report, based on severity of incident (Safety Assessment Code (SAC)) score, classification of report and reporter occupation, that prompted reviewer feedback and stimulated organisational change. Methods Incident reports registered within the RiskMan data repository between January to December 2020 were collated. During the 12-month period, a total of 2250 reports were recorded within the data repository. Feedback was provided for 71 of these reports, with 19 of these reports constituting organisational change. Results Four key findings were determined by the study. Deterioration was the most likely classification of the incident report to receive feedback, as well as feedback of organisational change. SAC 1 reports were significantly more likely to receive feedback than SAC 3 & 4. There was no significant difference in receiving organisational change feedback between SAC 1 and SAC 2. Incident reports by ‘medical’ staff were significantly more likely to receive feedback than ‘nursing’, ‘admin’, and ‘other’ occupations. Conclusions This study identified characteristics of incident reporting that result in organisational change recommendations. The small number of incident reports that received feedback is an area for improvement in this clinical site. Understanding the nature of the incident reports that are prioritised when making organisational change can shed light on further areas for improvement. Future investigations could examine which recommendations were implemented, as well as evaluate the barriers and enablers to executing change.