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Critical Incident Techniques and Reflection in Nursing and Health Professions Education

Systematic narrative review.

Steven, Alison PhD, RN; Wilson, Gemma PhD; Turunen, Hannele PhD, RN; Vizcaya-Moreno, M. Flores PhD, RN; Azimirad, Mina MNSc, RN; Kakurel, Jayden PhD; Porras, Jari PhD; Tella, Susanna PhD, RN; Pérez-Cañaveras, Rosa PhD, RN; Sasso, Loredana MEdSc, RN; Aleo, Giuseppe PhD; Myhre, Kristin PhD, RN; Ringstad, Øystein PhD; Sara-Aho, Arja RN; Scott, Margaret RN; Pearson, Pauline PhD, RN

Author Affiliations: Professor of Research in Nursing and Health Professions Education (Dr Steven) and Vice Chancellors Fellow (Dr Wilson), Department of Nursing, Midwifery and Health, Northumbria University, United Kingdom; Professor of Nursing (Dr Turunen) and PhD Student (Ms Azimirad), Department of Nursing Science, University of Eastern Finland, Finland; Associate Professors (Drs Vizcaya-Moreno and Pérez-Cañaveras), Nursing Department, University of Alicante, Spain; Postdoctoral Researcher (Dr Kakurel), Copenhagen Centre for Health Technology, Denmark; Professor of Innovation & Software (Dr Porras), Department of Innovation & Software, Lappeenranta University of Technology, Finland; Senior Lecturer (Dr Tella) and Lecturer (Ms Sara-Aho), Faculty of Health Care and Social Services, Saimaa University of Applied Sciences, Finland; Professor of Nursing (Ms Sasso) and Lecturer, (Dr Aleo), Department of Health Sciences, University of Genoa, Italy; Associate Professors (Drs Myhre and Ringstad), Østfold University College, Norway; and Senior Lecturer (Ms Scott) and Professor of Nursing (Dr Pearson), Department of Nursing, Midwifery and Health, Northumbria University, United Kingdom.

The authors declare no conflicts of interest.

Correspondence: Dr Steven, Department of Nursing, Midwifery and Health, Northumbria University, Coach Lane Campus, Benton, Newcastle upon Tyne, United Kingdom NE7 7XA ( [email protected] ).

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.nurseeducatoronline.com ).

Accepted for publication: November 19, 2019

Published ahead of print: January 14, 2020

Cite this article as: Steven A, Wilson G, Turunen H, et al. Critical incident techniques and reflection in nursing and health professions education: systematic narrative review. Nurse Educ . 2020;45(6):E57-E61. doi: 10.1097/NNE.0000000000000796

Background 

The terms critical incident technique and reflection are widely used but often not fully explained, resulting in ambiguity.

Purpose 

The aims of this review were to map and describe existing approaches to recording or using critical incidents and reflection in nursing and health professions literature over the last decade; identify challenges, facilitating factors, strengths, and weaknesses; and discuss relevance for nursing education.

Methods 

A systematic narrative review was undertaken. MEDLINE and the Cumulative Index to Nursing and Allied Health Literature were searched using MeSH terms, returning 223 articles (2006-2017). After exclusions, 41 were reviewed.

Results 

Articles were categorized into 3 areas: descriptions of the development of an original tool or model, critical incidents or reflection on events used as a learning tool, and personal reflections on critical incidents.

Conclusions 

Benefits have been identified in all areas. More attention is needed to the pedagogy of reflection and the role of educators in reflection.

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Critical Thinking in Nursing: Tips to Develop the Skill

4 min read • February, 09 2024

Critical thinking in nursing helps caregivers make decisions that lead to optimal patient care. In school, educators and clinical instructors introduced you to critical-thinking examples in nursing. These educators encouraged using learning tools for assessment, diagnosis, planning, implementation, and evaluation.

Nurturing these invaluable skills continues once you begin practicing. Critical thinking is essential to providing quality patient care and should continue to grow throughout your nursing career until it becomes second nature. 

What Is Critical Thinking in Nursing?

Critical thinking in nursing involves identifying a problem, determining the best solution, and implementing an effective method to resolve the issue using clinical decision-making skills.

Reflection comes next. Carefully consider whether your actions led to the right solution or if there may have been a better course of action.

Remember, there's no one-size-fits-all treatment method — you must determine what's best for each patient.

How Is Critical Thinking Important for Nurses? 

As a patient's primary contact, a nurse is typically the first to notice changes in their status. One example of critical thinking in nursing is interpreting these changes with an open mind. Make impartial decisions based on evidence rather than opinions. By applying critical-thinking skills to anticipate and understand your patients' needs, you can positively impact their quality of care and outcomes.

Elements of Critical Thinking in Nursing

To assess situations and make informed decisions, nurses must integrate these specific elements into their practice:

• Clinical judgment. Prioritize a patient's care needs and make adjustments as changes occur. Gather the necessary information and determine what nursing intervention is needed. Keep in mind that there may be multiple options. Use your critical-thinking skills to interpret and understand the importance of test results and the patient’s clinical presentation, including their vital signs. Then prioritize interventions and anticipate potential complications. 
• Patient safety. Recognize deviations from the norm and take action to prevent harm to the patient. Suppose you don't think a change in a patient's medication is appropriate for their treatment. Before giving the medication, question the physician's rationale for the modification to avoid a potential error. 
• Communication and collaboration. Ask relevant questions and actively listen to others while avoiding judgment. Promoting a collaborative environment may lead to improved patient outcomes and interdisciplinary communication. 
• Problem-solving skills. Practicing your problem-solving skills can improve your critical-thinking skills. Analyze the problem, consider alternate solutions, and implement the most appropriate one. Besides assessing patient conditions, you can apply these skills to other challenges, such as staffing issues . 

How to Develop and Apply Critical-Thinking Skills in Nursing

Critical-thinking skills develop as you gain experience and advance in your career. The ability to predict and respond to nursing challenges increases as you expand your knowledge and encounter real-life patient care scenarios outside of what you learned from a textbook. 

Here are five ways to nurture your critical-thinking skills:

• Be a lifelong learner. Continuous learning through educational courses and professional development lets you stay current with evidence-based practice . That knowledge helps you make informed decisions in stressful moments.  
• Practice reflection. Allow time each day to reflect on successes and areas for improvement. This self-awareness can help identify your strengths, weaknesses, and personal biases to guide your decision-making.
• Open your mind. Don't assume you're right. Ask for opinions and consider the viewpoints of other nurses, mentors , and interdisciplinary team members.
• Use critical-thinking tools. Structure your thinking by incorporating nursing process steps or a SWOT analysis (strengths, weaknesses, opportunities, and threats) to organize information, evaluate options, and identify underlying issues.
• Be curious. Challenge assumptions by asking questions to ensure current care methods are valid, relevant, and supported by evidence-based practice .

Critical thinking in nursing is invaluable for safe, effective, patient-centered care. You can successfully navigate challenges in the ever-changing health care environment by continually developing and applying these skills.

Images sourced from Getty Images

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Examples of Critical Healthcare Incidents In Healthcare

Medical catastrophes of all kinds happen. Physicians, nurses, therapists, and healthcare administrators train, plan, and prepare as much as they can, but it’s nearly impossible to account for everything. Patients suffer undue harm – but so do the providers who must deal with the emotional, physical, and psychological effects of these examples of critical incidents in healthcare.

What Are Examples of Critical Incidents in Healthcare?

The National Institutes of Health (NIH) define critical incidents (CIs) as “unexpected events that may reach patients and thus threaten patient safety.” What NIH doesn’t list is how those unexpected patient safety events impact the providers directly and indirectly involved.

Examples of incidents in healthcare can include:

• Serious injury (burn, cut, puncture wound, fall)
• Misdiagnosis that results in serious injury or death
• Surgical procedure on wrong body part
• Caregiver neglect
• Receive the wrong medication or incorrect dosage
• Natural disasters that affect patient safety and care
• Human-caused events (fire, flood, assault, criminal activity)

Critical Incident Impact on Healthcare Providers

A 2023 study by Thriving in Health showed that healthcare providers are not “immune to the psychological impacts of critical incidents.” According to researchers, the effects that healthcare providers often deal with include:

Nearly three-fourths (71%) of emergency department staff reported mild post-traumatic stress disorder (PTSD) symptoms with 20% saying they had moderate PTSD. Ambulance staff reported alcohol-related problems rose from 1.2% to 11.6% following exposure to an adverse incident.

Minimize Critical Incident Effects With Detailed Reporting

Following critical events, healthcare providers benefit from mental health counseling, workload management, and support from managers and executive leadership. Another healing benefit is how the organization responds to the incident and what measures are taken to prevent recurrences.

Dynamic incident reporting systems are a great way to ensure responsible parties are aware of critical events and empowered with data to safeguard healthcare staff and patients in the future.

An incident report is thorough documentation of the event , including all relevant details that caused it and any outcomes that stemmed from it. The key to a good incident report is completeness and accuracy, and that means documenting as much information as possible.

Critical Incident Reporting in Healthcare Facilities

Impactful incident reporting requires healthcare management to remove barriers so that staff can document and take responsibility for incidents. A digital incident reporting system makes that easier by with:

• Accessibility: Digital platforms or mobile apps offer 24/7 access for easy reporting from anywhere.
• Ease of use:   With an online system it is easy to customize as many different report types as needed so you can get exactly the information needed without extra questions or confusing fields. Plus it’s easy to track and analyze.
• Easy to escalate: Many online solutions offer customizable escalation processes that are automatic when the report is completed. You choose the people to be notified based on report type, location, and more.
• Anonymous: Anonymous reports strengthen policies and systems to protect the confidentiality of both the reports and the identities of reporters.
• Quick resolution: When the report is immediately forwarded to the appropriate managers, action and resolution can happen more quickly.
• Unlimited templates: Create templates for nearly all examples of incidents in healthcare to make it easier for employees to provide the needed information.

Digital incident reporting solution . It can help to create the proactive reporting culture you desire, eliminate delays, identify trends, and resolve issues more quickly.

MedTrainer offers all the functions listed above in an all-in-one compliance solution. Enhance your compliance programs with digital incident reporting solutions for any size organization. Contact us to learn more.

Streamline your compliance with MedTrainer

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‘I hope the next Darzi report will be a positive story about NHS progress’

STEVE FORD, EDITOR

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Reflective thinking: turning a critical incident into a topic for research

01 January, 2004 By NT Contributor

Malcolm Elliott, BN, MN, RN.

Lecturer, Department of Nursing, University of Wollongong, New South Wales, Australia

A critical incident is one which causes a person to pause and contemplate the events that have occurred to try to give them some meaning. 

This may be a positive experience or a negative one. Using a critical incident as a way of reflecting involves the identification of behaviour deemed to have been particularly helpful or unhelpful in a given situation (Hannigan, 2001).

In nursing, for example, a critical incident could take the form of a medication error, a nosocomial infection or helping a patient achieve a comfortable, dignified death. These events might be labelled as ‘critical incidents’ because they encourage nurses to reflect on what has happened, to challenge their practice or to resolve to do better next time. Identifying the nature and sources of critical incidents presents the opportunity to raise the educational profile of the skills needed to address these issues (Perry, 1997).

Critical incidents can also be used as a basis for clinical research projects. According to Hagland (1998), almost everyone at some time considers how things could have been avoided, overcome or improved. Good research projects often start with the identification of a problem and those projects which solve or eliminate clinical problems are the most worthwhile. And, as Polit and Hungler conclude, the answers to nursing research questions help nurses provide more effective nursing care and document the unique role nursing plays in the health-care system (1993).

The path, however, from critical incident to a researchable question is not an easy one. Many nurses are intimidated by the thought of carrying out research because they have not done it before, the research process is foreign to them or because they feel they do not have a topic or question than needs answering.

Page and Meerabeau (2000) believe that if the reflector perceives themselves to be in a powerless position to orchestrate changes or suffers from professional apathy, learning and practice are unlikely to be advanced. Thus successful reflection is as much about the attitude of the clinician as the topic or theme being explored.

Reid (1993) defined reflection as a process of reviewing an experience of practice in order to describe, analyse, evaluate and so inform learning about practice. There are a number of benefits of reflective practice (Box 1).

Reid (1993) adds that reflective practice is potentially both a way of learning and a mode of survival and development once formal education ceases. In fact it challenges the concept of education as a once-and-for-all experience. It is an effective self-learning and teaching tool for professional growth and is a key way of improving nurses’ professional standing (Lian, 2001).

Taking critical incidents further

The aim of this paper is to describe the process a clinical nurse, who might be an inexperienced researcher, can use to create researchable questions from clinical incidents. This aim will be achieved by describing the critical process used by the author to generate potential research questions from an incident. The paper will conclude by describing the advantages of the reflective process in generating research questions.

Reflection on action (rather than in action) was used to examine this event. One of the main criticisms of this type of reflection is that, because the outcome is known, the development of practical knowledge may actually be inhibited by its influence (Page and Meerabeau, 2000).

The validity of this criticism depends very much on the specific nature of the incident being reflected upon. It will be seen from the incident described here that the outcome does not affect the development of knowledge but in fact raises or highlights many researchable topics.

When asked to think of a critical incident, there is the temptation to try to think of an experience in which one ‘saved the world’ or alternatively ‘negative’ incidents in which one has been involved.

Students in a study by Smith and Russell (1991) experienced such difficulties. An easy trap to fall into when trying to identify a critical incident is to focus on one’s negative experiences, make broad generalisations from them and to try to use these as a basis for research. Although this can generate researchable questions, it is probably easier to develop questions and a research project through passion and enthusiasm rather than anger and bitterness. It is for this reason that one must be objective when reflecting on a subjective incident.

To consider what to research, the author reflected on incidents in which he had been involved and had strong feelings about or which were a source of great frustration. This opened the door to many incidents. The incident chosen for further exploration was the readmission of a patient to the intensive care unit (ICU) soon after he had been discharged to a general ward.

A suitable critical incident

The next step in the reflective process is to write a description of the incident selected in an attempt to identify some themes.

The patient concerned was a man in his fifties who was struck by a car. Although he had no injuries to the head, chest or spine, he was in ICU because of hypovolaemic shock related to abdominal bleeding. His major injuries were orthopaedic, involving extensive fractures to both of his legs and significant tendon damage.

The author first encountered the patient when he was in the high-dependency unit (HDU) attached to the ICU. He had been in the ICU for about three months due to complications related to an exploratory laparotomy performed to find a source of his bleeding. Although no major abdominal injuries were found, his abdomen became a source of sepsis and, ultimately, septic shock postoperatively.

The day the author cared for him, the patient had a tracheostomy in situ. He was breathing spontaneously but his airway required regular suctioning. He was conscious and able to communicate but at times seemed withdrawn and unresponsive to the environment he was in. He had significantly reduced movement and sensation in both of his legs, obviously related to the trauma.

The incident occurred when the author returned to work for a morning shift after having a few days of annual leave. The patient was no longer in the HDU. He had been sent to the orthopaedic ward the previous afternoon. However, a few hours later on that same morning shift, the patient was readmitted to the ICU after experiencing a respiratory arrest in the ward.

This was a critical incident for a number of reasons. First, there was anger because the hard work of the ICU and HDU staff appeared to have been wasted. The ICU staff had spent weeks weaning the patient off the ventilator and giving him intensive nursing and medical care, and now he was back where he started. Also, although his condition had been stable for a number of days before discharge, there was concern that his family might feel that we had discharged him prematurely and thus mismanaged or neglected him.

There was the desire as well to blame someone and the ward staff were an easy target. Page and Meerabeau (2000) warn that: ‘The whole business of reflection carries the potential for harm for the reflector as they may have to confront challenges to cherished beliefs and ideals, or come into conflict with peers as a result of the new insight reflection has afforded them.’ This may in fact be an advantage because, by challenging the way we practise our craft, the potential for better quality care or improved outcomes can be reached.

One or two negative clinical experiences such as the above incident can easily make one frustrated and angry at the health-care system and its inability to meet the needs of the people it is designed to serve. In reality, the effectiveness of the system is probably related to the abilities of the clinicians that work in it and particularly their ability to work as a team.

It is also possible to be influenced by the ‘blame culture’ in nursing, in which we do not hesitate to blame each other for complications a patient experiences even though it may be our own fault.

The next step in the reflective process is to identify some themes or issues that the incident ‘created’ or highlighted. Box 2 lists some of the these. The list is far from exhaustive and each theme is complex and has various questions associated with it.

Literature review

The next step in the reflective process is to review the literature, with the hope of acquiring insight into the incident and its themes. Two main databases were used: CINAHL and Medline. The world wide web was also searched. Search terms used were ‘readmission’, ‘intensive care’, ‘critical care’, ‘high-dependency’ and ‘bounce back’.

Readmission rates - From wards to ICU readmission rates are between 5 and 10% (Chen et al, 1998; Cooper et al, 1999; Durbin and Kopel, 1993; Snow et al, 1985), though some literature cited rates between 10 and 19% (Baigelman et al, 1983; Franklin and Jackson, 1983; Levy et al, 2001). Of significance is that published readmission rates have not changed much in the past 20 years.

Reasons for readmission - Common reasons for readmission to ICU are cardiovascular or cardiopulmonary dysfunction, which includes aspiration or bacterial pneumonia, pulmonary oedema, respiratory failure, sputum retention and respiratory arrest (Chen et al, 1998; Cooper et al, 1999; Levy et al, 2001; Russell, 1998; Wallis et al, 1997).

Gaps in the literature - The actual or specific causes of these clinical problems were often missing, suggesting new areas for research. Other gaps in the literature included:

- What factors influence the care patients discharged from ICU receive in general wards?

- Is a breakdown in continuity of care responsible for patients being readmitted to ICU?

- What are clinicians’ opinions on why patients are readmitted to ICU?

This list is certainly not complete and does not address every potential question arising from the literature review.

A literature review must also examine the methodology used in the studies reviewed. Most of the studies were performed by medical researchers and were retrospective reviews of either medical databases or patients’ medical records. There were few studies performed by nurse researchers that addressed the readmission theme. Mostly these studies examined issues such as ward nurses’ experiences of caring for patients transferred from ICU or their thoughts and opinions about caring for these patients. Data were collected through questionnaires or surveys. The literature provided insight into some of the themes listed earlier. However, many remained unexplored and it also raised questions for future research.

Choosing a theme for research

The next stage after the literature review is to choose the direction to take: to explore issues arising from critical reflection of the nurse’s own experience or tackle one of the questions from the studies already published. The author has chosen to explore issues arising from his own experience, to give him ownership of the project.

The aim of the proposed research study will be to explore why patients are readmitted to ICU from general wards, specifically by asking clinicians their opinions. Clinicians include registered nurses who work in general wards and ICU, and senior medical staff who work in ICU. Obviously there are many other questions or themes that could be explored, but a sound research project needs to have a very specific focus. The methodology of the study will include semi-structured interviews of clinicians. Recruitment is ongoing.

As can be seen, the path from a critical incident to a researchable topic need not be complex. Nurses frequently experience critical incidents in their professional practice. These incidents can be a source of great frustration because, by their complex nature, their meaning or significance is not obvious. However, these incidents also provide a wealth of learning opportunities as well as potential research projects.

Nurses can use the reflective process to identify the underlying themes of these incidents, which may then serve as the basis for a research proposal.

There are numerous benefits to using the reflective process in this way. One of the main ones is that with a little time, effort and minimal expense, the nursing workforce can advance its practice and become knowledgeable doers who deliver quality care by virtue of the critical insights gained through reflection (Page and Meerabeau, 2000).

Although the reflective process described here was performed under supervision as part of a postgraduate nursing course, such supervision is not necessary, even for the inexperienced reflector, to produce worthwhile researchable topics.

Nurses probably use the reflective process in their everyday practice without being consciously aware that they are doing so. By formalising or structuring their thought processes, not only is fresh or new insight obtained, but specific researchable questions can be formulated.

This paper has provided on overview of what a critical incident is and what the reflective process involves. It has described how the author applied the reflective process to a critical incident and by doing so was able to generate a researchable topic.

- The author would like to thank Professor Patrick Crookes, Head of the Department of Nursing, University of Wollongong, Australia, for editorial assistance.

Baigelman, W., Katz, R., Geary, G. (1983)   Patient readmission to critical care units during the same hospitalization at a community teaching hospital. Intensive Care Medicine 9: 253-256.

Baker, C. (1996) Reflective learning. Journal of Nursing Education 35: 1, 19-22.  

Chen, L., Martin, C., Keenan, S., Sibbald, W. (1998) Patients readmitted to the intensive care unit during the same hospitalization. Critical Care Medicine 26: 11, 1834-1841.

Cooper, G., Sirio, C., Rotondi, A. et al. (1999) Are readmissions to the intensive care unit a useful measure of hospital performance? Medical Care 37: 4, 399-408.

Davies, E. (1995) Reflective practice. Journal of Nursing Education 34: 4, 167-174.

Durbin, C., Kopel, R. (1993) A case-control study of patients readmitted to the intensive care unit. Critical Care Medicine 21: 10, 1547-1553.

Franklin, C., Jackson, D. (1983) Discharge decision-making in a medical ICU. Critical Care Medicine 11: 2, 61-66.

Ghaye, T., Lillyman, S. (1997) Learning Journals and Critical Incidents Wiltshire: Quay.

Hagland, M. (1998) Reflection: a reflex action? Intensive and Critical Care Nursing 14: 2, 96-100.

Hannigan, B. (2001) A discussion of the strengths and weaknesses of reflection in nursing practice and education. Journal of Clinical Nursing 10: 278-283.

Hendricks, J., Mooney, D., Berry, C. (1996) A practical strategy approach to use of reflective practice in critical care nursing. Intensive and Critical Care Nursing 12: 2, 97-101.

Jay, T. (1995) The use of reflection to enhance practice. Professional Nurse 10: 9, 593-596.

Johns, C. (1995) The value of reflective practice for nursing. Journal of Clinical Nursing 2: 4, 23-30.

Levy, M., Greene, L., Ramsay, M. et al. (2001) Readmission to the intensive care unit after liver transplantation. Critical Care Medicine 29: 1, 18-24.

Lian, J.X. (2001) Reflective practice: a critical incident. Contemporary Nurse 10: 3-4, 217-221.

Mallik, M. (1998) The role of nurse educators in the development of reflective practitioners. Nurse Education Today 18: 1, 52-63.

Page, S., Meerabeau, L. (2000) Achieving change through reflective practice. Nurse Education Today 20: 5, 365-372.

Perry, L. (1997) Critical incidents, crucial issues. Journal of Clinical Nursing 6: 2, 131-137.

Polit, D., Hungler, B. (1993) Essentials of Nursing Research (3rd edn). Philadelphia, Pa: Lippincott

Reid, B. (1993) But we’re doing it already! Exploring a response to the concept of reflective practice in order to improve its facilitation. Nurse Education Today 13: 4, 305-309.

Russell, S. (1998) Life After Life-support. Melbourne, Victoria: University of Melbourne.

Smith, A., Russell, J. (1991) Using critical learning incidents in nurse education. Nurse Education Today 11: 4, 284-291.  

Snow, N., Bwegin, K., Horrigan, T. (1985) Readmission of patients to the surgical intensive care unit: patient profiles and possibilities for prevention. Critical Care Medicine 13: 11, 961-964.

Wallis, C., Davies, H., Shearer, A. (1997) Why do patients die on general wards after discharge from intensive care units? Anaesthesia 52: 1, 9-14.

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Addressing Patient Safety Hazards Using Critical Incident Reporting in Hospitals: A Systematic Review

Ken goekcimen.

From the ∗ Department of Dermatology

René Schwendimann

† Patient Safety Office, University Hospital Basel

‡ Department Public Health, Institute of Nursing Science, University of Basel, Basel

Yvonne Pfeiffer

§ Research Department, Patient Safety Foundation, Zurich, Switzerland.

Giulia Mohr

Christoph jaeger, simon mueller, associated data, introduction.

Critical incident reporting systems (CIRS) are in use worldwide. They are designed to improve patient care by detecting and analyzing critical and adverse patient events and by taking corrective actions to prevent reoccurrence. Critical incident reporting systems have recently been criticized for their lack of effectiveness in achieving actual patient safety improvements. However, no overview yet exists of the reported incidents’ characteristics, their communication within institutions, or actions taken either to correct them or to prevent their recurrence. Our main goals were to systematically describe the reported CIRS events and to assess the actions taken and their learning effects. In this systematic review of studies based on CIRS data, we analyzed the main types of critical incidents (CIs), the severity of their consequences, their contributing factors, and any reported corrective actions.

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we queried MEDLINE, Embase, CINAHL, and Scopus for publications on hospital-based CIRS. We classified the consequences of the incidents according to the National Coordinating Council for Medication Error Reporting and Prevention index, the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, and all corrective actions taken according to an action hierarchy model on intervention strengths.

We reviewed 41 studies, which covered 479,483 CI reports from 212 hospitals in 17 countries. The most frequent type of incident was medication related (28.8%); the most frequent contributing factor was labeled “active failure” within health care provision (26.1%). Of all professions, nurses submitted the largest percentage (83.7%) of CI reports. Actions taken to prevent future CIs were described in 15 studies (36.6%). Overall, the analyzed studies varied considerably regarding methodology and focus.

Conclusions

This review of studies from hospital-based CIRS provides an overview of reported CIs’ contributing factors, characteristics, and consequences, as well as of the actions taken to prevent their recurrence. Because only 1 in 3 studies reported on corrective actions within the healthcare facilities, more emphasis on such actions and learnings from CIRS is required. However, incomplete or fragmented reporting and communication cycles may additionally limit the potential value of CIRS. To make a CIRS a useful tool for improving patient safety, the focus must be put on its strength of providing new qualitative insights in unknown hazards and also on the development of tools to facilitate nomenclature and management CIRS events, including corrective actions in a more standardized manner.

In patient care, critical incidents (CIs) are unexpected events that may reach patients and thus threaten patient safety. By allowing reporting and analysis of such events, critical incident reporting systems (CIRS) 1 are expected to induce organizational learning from these events and near misses to improve the safety of healthcare organizations before a sentinel event happens. 2 Thus, they play a role of leading indicators to highlight the importance of CIRS and near misses for organizational learning. Critical incident reporting systems offer potential value as risk management instruments. 3 Therefore, most health care institutions in industrialized countries are legally obliged to have them in place and to maintain strategies to optimize patient safety. 4 , 5 Nonetheless, CIRS are increasingly falling into disrepute for not being effective in sustainable improving patient safety. 6 , 7

These systems depend on hospital staff to recognize and report incidents using standard report forms. These are then reviewed by a team of expert clinicians chosen for their abilities to analyze and manage risk. 6 , 7 Depending on each reported CI’s severity (e.g., the expert team’s risk assessment rating 8 ), a causal analysis may be conducted and corrective or preventive feedback may be provided. That is, this information will be disseminated as appropriate within the institution. 9 , 10 This way, CIRS are intended to contribute to continuous improvement loops.

However, CIRS are subject to major limitations. These include underreporting, 7 which reflects both their voluntary nature and the characteristics of each institution’s safety culture. If CI reports are misused to allocate blame, for example, staff members may hesitate to submit them. In addition, unless CIs lead to patient harm, the reported information is commonly difficult to validate. 11 Similarly, gaps in the information regarding an incident’s context, which is rarely fully transmissible using a reporting form, interfere with a causal analysis of that incident.

Furthermore, when Liukka et al 12 studied a web-based incident reporting database (HaiPro, used in over 200 social service and health care organizations in Finland) from 16,019 incident reports over a 5-year period, they found that extremely few of the examined CI reports (2.7%) triggered written recommendations to prevent recurrences of the reported incident. This finding illustrates how disruption of the flow of information can limit its effectiveness. In line with prior research, 13 Jäger et al’s longitudinal analysis of 5493 CIs demonstrated that the “feedback loop”—the cycle of information, action and improvement made possible by CIRS data—was clearly underused. 14

Within a functional feedback loop, reported instances of patient safety hazards become data for causal analyses; the results of those analyses allow elimination or reduction of the identified causes. By increasing patient safety, this process is expected to improve future care. However, the latest World Health Organization report on CIRS notes that as many incident reports remain unaddressed, their current use often leads to few real improvements; that is, CIRS data are largely wasted. 2

As CIRS are used in hospitals worldwide, numerous studies discuss aspects of learning from reported incidents. Unfortunately, comparable information on the characteristics of the reported CIs, as well as comparative reviews on corrective actions following reported CIs, is currently lacking. To address this shortfall, we set 2 main objectives for the current review: first, to systematically analyze hospital-based CIRS studies regarding each reported incident’s type, severity, and contributing factors and, if possible, second, to evaluate the actions taken to prevent further such incidents.

This systematic review was conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. 15

Search Strategy

We searched the MEDLINE, Embase, CINAHL, and Scopus databases. Our queries used 4 normal-text strings—“Critical Incident Reporting System,” “Incident Reporting System,” “Critical Incident Reporting” and “Patient Safety Learning System”—and the following MeSH terms and Boolean operators (including parentheses): (“Hospitals”[Mesh] OR “Patients” [Mesh] OR “Inpatients”[Mesh] OR hospital*[tiab] OR Patient*[tiab] OR inpatient*[tiab]) AND (“Medical Errors/methods”[Mesh] OR “Medical Errors/statistics and numerical data”[Mesh] OR “Risk Management/methods”[Mesh] OR “Risk Management/statistics and numerical data”[Mesh]) AND (Critical Incident*[tiab] OR Incident Reporting*[tiab] OR Near Miss*[tiab] OR Safety Incident*[tiab]).

Inclusion and Exclusion Criteria

We included observational studies using data from established hospital-based CIRS that reported CIs’ characteristics and/or improvement actions. To be eligible for inclusion, studies had to be published between 2000 and 2019 in English or German, use compatible definitions of CI reporting (i.e., incidents that affected or could have affected 1 or more patients’ safety), 1 and include data from a minimum of 100 reports. We excluded studies from national and statewide reporting systems, 16 – 18 those in nonhospital settings 19 , 20 (e.g., primary care, nursing homes), and those for reporting specific incident types 21 , 22 (e.g., falls, equipment, transfusions).

Data Extraction, Quality Assessment, and Analysis

All titles and abstracts of the identified articles were independently screened for eligibility by 2 reviewers and arbitrated by a third to reach consensus in cases of disagreement. For data extraction, we used 2 forms: (1) study characteristics, that is, author(s), publication year, country of origin, setting/sample, study design, the used definition of CIs, and study duration in months and (2) incident-related details, that is, characteristics/types, consequences, contributing factors, and organizational actions taken/lessons learned. We classified the incidents’ consequences according to the National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP) index, 23 the contributing factors according to the Yorkshire Contributory Factors Framework and the Human Factors Classification Framework, 24 , 25 and any actions taken according to an action hierarchy model on strengths of interventions to improve patient safety as proposed in the literature. 26 , 27

For quality assessment, as no specific critical appraisal tools are available for studies on “critical incident reporting systems.” Two authors (K.G., R.S.) assessed each study’s reporting methodology, that is, they decided whether its included information was adequately structured—first on the basic characteristics of each reported CI (type, consequences/severity, contributing factors) and then on the actions taken to prevent that CI’s recurrence. Disagreements between the 2 study reviewers were discussed until consensus was reached. Based on this process, they narrowed our literature search’s 3621 initial returns to 41 that were eligible for detailed review (Fig. ​ (Fig.1 1 ).

Flow diagram of article retrieval.

Study Characteristics

The 41 included studies were conducted between 2004 and 2019 and referred to 479,483 analyzed reports from 212 hospitals. The majority were conducted in Europe (n = 21, 51.2%), followed by North and South America (n = 13, 31.7%), Asian (n = 6, 14.6%), and Middle Eastern (n = 1, 2.4%) regions. Thirty were single-center studies; 11 were multicenter. For the single-center group, incident report sample sizes ranged from 114 28 to 8809. 29 For the multicenter group, the numbers of included hospitals ranged from 2 to 29, with CI numbers ranging from 584 30 to 266,224. 31 Across all studies, durations ranged from 12 to 132 months. Settings included “university/academic/teaching hospitals” (n = 29), “acute care hospitals” (n = 23), “suburban hospitals” (n = 13), “urban hospitals” (n = 11), “tertiary hospitals” (n = 7), “quaternary hospitals” (n = 3), “rural hospitals” (n = 2), and “community hospitals” (n = 1); for the remaining 147, no hospital type was specified. Critical incident–reporting clinical departments included surgical disciplines, anesthesia, standard, pediatric and neonatal intensive care units, pediatrics, internal medicine, emergency, ophthalmology, and radiology (see supplementary file, http://links.lww.com/JPS/A508 , summarized study characteristics).

Reporter Characteristics

In 22 of the 41 studies (53.6%), the incident reporters’ professions were specified. Of these 22 studies’ reporters, 83.7% were nurses (range, 0.8% 32 –84.7% 33 ), 6.5% pharmacists (range, 1% 34 –51.9% 35 ), 4.8% physicians (range, 1.1% 31 –50.3% 36 ), and 5% other professions, including laboratory technicians, paraclinical staff, dieticians, etc (range, 0.1% 33 –10% 37 ). 33 , 34 , 37 – 43 In 2 studies, 32 , 36 most reports were made by physicians. In 1 study, 44 apart from “physician,” no professions were specified.

Incident Types

In 35 of the 41 included studies (85.4%, n = 467,616 CIs), the types of CI were specified (Fig. ​ (Fig.2). 2 ). The 3 most commonly reported CI categories were: medication related (28.8%; range, 3.4% 45 –63.3% 46 ), administration related (12.9%; range, 2.3% 45 –18.9% 47 ), and fall related (11.5%; range, 0.2% 40 –16.6% 29 ). In 1 study, 31 adverse clinical events were classified as events related to medical treatment. Across the 24 studies (58.5%) that provided CI incidences, these ranged from 1.6 48 to 103 40 reported CIs per 1000 patient days (overall mean, 28 CI reports per 1000 patient days).

Types of reported critical incidents.

Consequences of Incidents

In 23 of the 41 studies (56.1%, n = 341,097 CIs), CIs’ consequences were reported. As recommended by the NCC MERP index, we divided these consequences into 5 groups, no error (circumstances or events that have the capacity to cause error), error, no harm (an error has occurred but has not caused any harm to the patient), error, harm (an error has occurred and harmed the patient), error, death (an error has occurred that could have contributed to or could have led to the death of the patient), and not coded (not classified; Fig. ​ Fig.3 3 ). 23 As detailed in Figure ​ Figure3, 3 , 21.7% (74,086/341,097) of incidents resulted in temporary or permanent patient harm, and 0.4% (1208/341,097) resulted in patient death.

Consequences of critical incidents according the NCC MERP index.

Contributing Factors

In 20 of our 41 chosen studies (48.8%), the authors indicated factors (n = 51,650) that contributed to the reported CIs (shown in Fig. ​ Fig.4). 4 ). Overall, the most frequent contributing factor was “active failure” (13,464/51,650, 26.1%), that is, failure regarding healthcare providers’ performance or behavior (e.g., carelessness, treatment errors, failure to meet standards). Additional main contributing factors were “communication” (6548/51,650, 12.7%), “patient factors” (4203/51,650, 8.1%) pointing to patient features (e.g., severity of diseases) that make care more difficult, and “individual factors” (4006/51,650, 7.8%), pointing to healthcare workers’ features that may contribute to active failure, such as inexperience. A secondary contributor was team-related factors (2734/51,650, 5.7%), which consisted of “team factors” (1214/51,650, 2.4%), “staff workload” (879/51,650, 1.7%), and “management of staff and staffing levels” (641/51,650, 1.2%).

Contributing factors according the Yorkshire Contributory Factors Framework.

Actions Taken

In 15 of our 41 studies (36.6%), organizational actions taken to prevent future incidents were reported. Of those 15, 13 provided 118 detailed examples of measures taken to improve patient safety (see supplementary file, http://links.lww.com/JPS/A508 , summarized study characteristics). Following the Institute for Healthcare Improvement’s action hierarchy (2015), 26 , 27 , 49 we divided those into three classes. Based on each action’s potential impacts on systems change and improvement, we labeled it as “strong” (n = 32, 27.1%), “intermediate” (n = 49, 41.5%), or “weak” (n = 37, 31.4%; Table ​ Table1). 1 ). Examples include improving the functionality of syringe pumps 33 (a “strong action”), the introduction of medication cards for emergency situations and frequently used medications 54 (an “intermediate action”), and a nurse-to-nurse check for intravenous pump settings (a “weak action”). 44

Example Actions Sorted Along the Hierarchy of Impact for Change (N = 118)

*As proposed in the action hierarchy model on strengths of interventions to improve patient safety. 26 , 27 , 49

In reviewing studies about using CIRS in a variety of acute care hospital types, focusing on corrective measures and learning from incidents to improve patient safety, this study provides an overview of the types of CIs reported, their contributing factors, the extent of patient harm that resulted, and the actions taken.

The first important result is that there is a lack of standards in reporting the results of studies on CIRS: rarely were analytical frameworks mentioned, the characteristics of a “critical incident” were defined inconsistently, and the CI categorizations varied broadly. For example, regarding the reported events’ consequences, the studies analyzed in our systematic review used highly heterogeneous terminology: only one 51 explicitly applied the NCC MERP index. 23 As this lack of standardization and classification of CIs across healthcare systems impedes interstudy comparisons, it slows progress.

The second important result from the review is the lack of evidence of effective organizational learning and improvement of patient safety so far, which is supported by prior claims to change or improve CIRS processes. 25 , 49 Remarkably, only approximately one third of the analyzed studies provided information on improvement actions that followed the analyses. Their main study focus was on the processes of information feeding into the CIRSs (reports, reporters, and consequences) rather than the actions taken. The vital tasks of translating the findings into strong actions that would increase patient safety were much less discussed. Therefore, as a standard feature, any future report on CIRS research should include details of how the CI reports were used to improve patient care using a framework for describing the corrective actions.

The 41 hospital-based CIRS studies covered by this systematic review identified 479,483 CI reports from 212 hospitals. Investigating which kinds of events were reported and by which professional group allows to shed light on the capability of CIRS as an instrument for identifying patient safety hazards. For example, nurses were responsible to varying degrees for more than 80% of the reported incidents, which also reflects that nursing staff provide a vast majority of frontline hospital care. 58 However, hazards within the physicians’ work processes may be underrepresented in the reports.

In line with prior research, 59 the most frequently reported CIs were categorized as “medication related” (28.8%). This ranking reflects the high potential for harm from errors in drug administration. 60 – 62 The second most reported class of CI (20.6%) was “unspecified clinical event”. As a catch-it all term, it is similar to “administrative error,” a classification also used in CIRS-related studies to indicate arrays of unspecified CIs. The vagueness of classification points to relevant, unsolved issues in learning from incidents: the causes of an event are subject to analyses and are influenced by the knowledge, perspective, and interests that the analysts bring with them. 63 The same event may be attributed different causes by different analyzing teams and at different points in time. For example, the classification of a report before it is analyzed may result in it being assigned to completely different categories than would be the case after analysis. A forgotten insulin administration, for example, may be considered an active failure due to inattention, while—after analysis—one may realize that it is also the result of a complex interplay between organizational factors, such as the usability of the medication chart, and the staffing around the time of administration. The topic “communication” also exemplifies the challenges of classifying CIs and their causes into meaningful categories: communication problems were attributed as causes for 12.7% of all CIs, apparently confirming communication’s “error proneness.” 64 In addition, several of our reviewed studies included communication both in “incident type” and “contributing factors” or even in other factor classes (e.g., “human factors,” 53 , 65 “individual (staff) factors” 48 ).

While CIRS can be used to identify hazards, previous research has concluded that the distribution of incident types cannot be used to assess the severity of reported problems or to compare them with one another 66 : different incident types’ reporting rates may reflect different motivational factors; errors in medication administration may be more readily reported than complex diagnostic errors that become evident only over time. In addition, the culture may be inducive to reporting or not, so that higher reporting rates do not reflect greater problems, but a better reporting culture. 67

Classifying contributing factors according to the Yorkshire contributory factors framework 25 allowed us to compare them across studies. The most frequently mentioned contributing factor was “active failure,” which encompasses a broad spectrum of factors in healthcare workers’ performance or behavior (e.g., carelessness, any failure regarding treatment processes or standards of medical care). 33 , 43 , 68 , 69 This is an important finding, because it illustrates a common limitation of learning from incidents: If the reports are mainly attributed to factors that are “visible” in the situation, rather than trying to find more latent systemic causes, the potential for organizational learning is basically restricted to local improvements. From research about root cause analysis, this tendency to blame the actors involved at the sharp end of an event is well known. 70 We therefore recommend based on this review finding that managers responsible for the analysis of incidents should closely track this tendency to assign the responsibility to frontline actors at the sharp end but also keep an eye on “the larger picture” with a more systematic approach. To this end, major changes in the use of CIRS may be necessary. Analyzing critical events, identifying systemic causes, and deriving strong actions demand considerable time and resources. Considering the current limited resources invested in healthcare CIRS, it would not allow to do this for every reported event. 2 Thus, groups of incidents reporting similar events can be pulled together and used to do a major analysis, for example. In addition, series of events were proposed to be used to shed light on a patient’s journey. 71 In this way, the strength of CIRS lies in providing new qualitative insights into unknown safety issues facing the healthcare organization rather than an unreliable count on an already known issues. 72

Furthermore, the details of CI circumstances are essential for their causal analysis; however, these cannot be fully considered in an anonymous written report. 73 , 74 Therefore, recent proposals have suggested to investigate broader time horizons, as well as the patients’ participation in the incident analyses. This would allow exam of the incident within the context of a patient’s journey. 71

While none of the reviewed studies applied the Yorkshire framework, 25 2 studies 48 , 51 referred to Reason’s 59 , 75 and Vincent’s 73 models of accident causation. None of the other studies applied a theoretical framework. As noted in a previous study, this omission suggests a lack of overall consistency. 13

Regarding the gravity harm involved, incidents not harming patients but clearly involving an error seem to be the most likely to be reported. This may be explained by the principle that as such errors result in actual occurrences, they are easier to detect than near misses. In addition, if no patients are harmed, many questions of personal responsibility are not raised in the analysis or are associated with less guilt, which might increase the motivation to report. However, poor staffing as system contributor to the occurrence of adverse events relates to excessive nurse workload and lower nurse-to-patient ratios as they are correlated with hospital mortality and morbidity as well as high levels of burnout, work absenteeism, and high job turnover among nurses. 76

The error types were reported only in few instances, however, without specifying them for example as error of omission. We did therefore not systematically assess them. However, the fact that the category “error of omission” is not mentioned may also indicate a bias in hazard identification using CIRS, as reporting forgotten or missed actions is less probable than reporting actual behavior.

For CIRS to be effective in improving patient safety, the corrective actions derived need to be defined, implemented, and followed up upon. In addition, deriving strong improvement actions not only also demands considerable resources but often requires actions outside the action repertoires of the participating individuals. 77 This means that if systemic causes such as staffing levels or issues in the design of work areas or instruments were identified as important contributors, strategic decisions on the hospital, or sometimes even on the regulatory, national level would need to be taken to generate and sustain strong systemic corrective actions. A good example is the design of healthcare information technology that is often involved in adverse events and that is hard to change from a local level but needs cooperation with industry and sometimes even regulatory demands to be improved. 78 Because of these limitations in power to invest resources and bring about systemic change within analysis teams, the causal analyses often derive corrective actions that are the direct cure of an identified issue. 79

Attributing incidents to active failures makes the process of identifying a corrective action that can also be implemented fairly simple. Readily available cures include warning signs, updated protocols, or training courses. Although all of these are quite easy to implement, because they target provider behavior, they are also known to offer rather low effectiveness in terms of reducing patient safety hazards. 49 , 80 As Kellogg et al 80 sobering illustrated, weak actions derived from event analyses failed to prevent events from recurring during their 8-year study period.

To sum up, the scattered and unsystematically reported evidence in learning from CIRS to improve patient safety paints a rather dire picture of the current situation. Thus, new ways of using CIRS need to be developed. As outlined previously, using reports as qualitative information for uncovering potentially unknown hazards could be a fruitful approach. New tools supporting causal analyses therefore are needed, and best practices in prioritizing action within CIRS management should to be urged 14 including schemes to decide which reports to analyze, which to observe, and how to analyze groups of similar incidents. Concerning insights from other instruments to detect patient safety hazards, such as morbidity/mortality conferences and patient complaints, need to be incorporated into the creation of a detailed and comprehensive picture of emerging hazards. Furthermore, we consider it useful to differentiate the target level of potential improvements to not only generate “quick fixes” on the local level, but also develop corrective actions that target systemic levels. Our study proposed framework for classifying incidents, contributory factors, and consequences, systematizing research and practice is an important baseline for improving the current CIRS to not generate waste, 14 but actual learning on departmental, hospital, and healthcare system level.

As a final note, we want to highlight that none of the studies systematically reported on the sustainability of the corrective actions or how and when a follow-up happened. This lack of long-term perspective is particularly outstanding, as CIRS aim at systemwide improvements for safety.

Limitations

While all of our reviewed studies focused on hospital CIRS, their broad heterogeneity, particularly regarding their methodologies and terminology, impeded the comparability of their data regarding, for example, types of incidents, contributing factors, or actions taken after a CI. Furthermore, as no specific tool was available to assess the quality of our selected CIRS-based studies, we based their eligibility entirely on our study aims. Using a pragmatic approach, our assessment depended heavily on each candidate study’s methodology and primary end points. Nevertheless, to support the comparability of our review findings, we addressed issues of study heterogeneity by applying the NCC MERP index and the Yorkshire contributory factors framework. Finally, for reporting and learning systems such as CIRS, no uniform nationwide legislations does exist across countries and their hospitals, although recommended by the World Health Organization.

CONCLUSIONS

This systematic review of studies of hospital-based CIRS data provides an overview of the characteristics of reported incidents, their contributing factors, their consequences, and their actions taken to prevent future incidents. Two main conclusions are drawn from the review: first, research on CIRS-related studies needs to systematize and align the reporting using frameworks to improve understandability and comparability of their results. Second, the reviews illustrate that there is only scarce evidence showing that systemic change in a hospital is initiated using a CIRS: there was a focus on situational, sharp-end factors in the analyses of the incidents; remarkably, only a third of the reviewed studies described the corrective actions taken; and the sustainability of the derived corrective actions was not addressed systematically. To make a CIRS a useful tool for improving patient safety, there is a need to focus on its strength in providing new qualitative insights into unknown hazards and also on developing tools to facilitate the nomenclature and management of CIRS events, including corrective actions, in a more standardized manner.

Supplementary Material

Acknowledgment.

The authors thank Dr Hannah Ewald, a database researcher, Library of the University of Basel, for her support in developing search strategies and Andrea Wiencierz, PhD, a senior statistician, Department of Clinical Research, University Hospital Basel, for statistics support.

The authors disclose no conflict of interest.

Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site ( www.journalpatientsafety.com ).

• DOI: 10.15226/2471-6529/3/1/00125
• Corpus ID: 53451318

Critical Incident Technique applied in nursing and healthcare sciences

• B. Fridlund , M. Henricson , J. Mårtensson
• Published 23 January 2017

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• Research article
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• Published: 07 August 2017

Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety

• Walter Petschnig 1 &
• Elisabeth Haslinger-Baumann 2  

Safety in Health volume  3 , Article number:  9 ( 2017 ) Cite this article

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The complexity of health care systems, the development of clinical approaches, and both scientific and technological advancements give rise to new requirements in clinical risk management. An expedient risk management is expected to deal with as many risks as possible to ensure patient safety. A prerequisite for a clinical risk management is a well-functioning error-reporting culture in health care organizations. The present study analysed the relationship between the Critical Incident Reporting System (CIRS) and patient safety. In particular, the aim of this work is to evaluate whether data from available sources provide sufficient evidence for the utility of CIRS and to derive recommendations for both theorists and practitioners. On paper, CIRS is expected to be useful in clinical settings because it allows the identification of weak spots, hazards, and critical situations such as ‘near misses’. However, neither a general CIRS database based on clinical reports exists nor a universal CIRS policy or CIRS direction has been established so far, which can be attributed to the inhomogeneity of the literature and the variability of approaches. Therefore, ordering and analysis of clinical reports are highly desirable.

First, inclusion criteria, exclusion criteria, and keywords were defined to collect studies, reviews, and other sources on CIRS from official databases. After the collection of appropriate articles, a description of the individual data is given. Then, data are classified into different sections based on their respective central statements, and a brief description is given. Finally, the reports are analysed in order to detect patterns and differences.

There is a close correlation between the establishment of CIRS in a health care organization and patient safety, although a quantitative relationship between reporting systems and safety is still unproven. CIRS allows the identification and implementation of appropriate actions and strategies toward patient safety. Several prerequisites were identified: top management commitment, transparency, training, anonymity, incentives, and an open error-reporting culture. Personnel have an important impact on the reduction of risk and on the development of safety. The leadership should accept the implementation of a “no blame” error and feedback culture and the security of an absolutely anonymous reporting system. The position of a risk or safety manager is highly recommended.

As immediate recommendations, health care organizations are encouraged to adopt CIRS. On the other hand, several research topics were identified, such as the quantitative relationship between CIRS and safety or the development of reliable incident-reporting indices and the ways on how to deal with them. Intensified empirically based research may help in answering open questions concerning CIRS.

A pivotal task in health care systems is to provide the best possible diagnosis and treatment of specific diseases. However, an increase in complexity, both time and cost pressure, and workload in conjunction with novel medical technologies may turn health care institutions and organizations into high-risk areas, suggesting risks for patients, negative consequences for health care organizations, and an increase of cost. A study by the Institute of Medicine [ 1 ] in 1999 has shown that between 44,000 and 98,000 Americans per year are dying due to avoidable errors in medication. For the first time, medical attendance errors are placed within the list of the ten most frequent causes of death before breast cancer or traffic accidents. Therefore, it is obvious that processes and even staff in the health care sector can be regarded as a source of risk. On the other hand, based on existing ethical policies and legal regulations, health care institutions and organizations are to regain and maintain patient confidence [ 2 ]. Therefore, they have to align processes and courses of action for the benefit of patients. To avoid risky measures, the implementation of a well-developed clinical risk management in conjunction with a “no blame” mission is one of several options in this optimization process.

In Germany and Austria, a matured error-reporting culture is not fully developed [ 3 ]. The establishment of a well-functioning error-reporting culture in health care institutions and organizations is often hampered by staff, which can be attributed to the fear of financial and personal consequences. More transparency in risk reduction processes in health care institutions and organizations is highly desirable [ 4 ]. In this context, several issues must be addressed:

The creation of a combined illustration of international results concerning voluntary incident-reporting systems such as the Critical Incident Reporting System (CIRS)

Verbalization of international, European, and national risk management requirements in health care facilities

Illustration of current quantitative and qualitative data concerning avoidable errors and frequency of errors, as well as damage to health with lethal consequence in relation to therapy and health care

The aim of this study is (i) to provide an overview on CIRS and its utility in clinical risk management; (ii) to gain insight in the institutional CIRS implementation processes, i.e. to provide a generic direction on how an efficient and sustainable adoption of CIRS in a clinical organization can be achieved; and (iii) to investigate the relationship between the CIRS application and patient safety.

Currently, neither national nor international reviews on CIRS exist. Therefore, a systematic literature review of available public sources was conducted in order to ascertain the impact of CIRS on clinical risk management and patient safety. A systematic review is expected to reduce the operator bias concerning the selection of relevant studies in comparison to a more conventional narrative literature review. The literature search was done in relevant literature databases including CINAHL, Cochrane Library, Google Scholar, MEDLINE, PubMed, and Thieme e-book library using a varying combination of German and English keywords (Table 1 ) between October 28, 2014, and May 25, 2015.

After this, predetermined exclusion criteria were used in order to identify and select the most relevant sources, which resulted in a core set of articles, paper, books, ‘grey literature’, etc. for data synthesis and analysis. In addition, the remaining abstracts of articles and full texts which were not taken into the core set were read for substantive relevance. Exclusion criteria were:

Outdated data (sources published up to 2005). There were four exceptions, i.e. sources which contained data of general importance.

No relationship between keywords found within the title, abstract, and content.

Inadequate virtual studies and literature reviews (minimum requirements: introduction, applied method, reasonable results, discussion, and conclusion).

No authorship and no date of publication.

No content relevant to ‘near misses’, i.e. exclusion of sources dealing solely with ‘adverse events’ or ‘sentinel events’.

Books and technical reports where the author(s) did not publish regular articles which can be found in regular databases so far.

After data collection, the articles were assigned to three categories: (i) studies and paper, (ii) reviews, and (iii) books and technical reports. The articles were searched for the following questions and issues:

What was reported?

Who has reported.

What were the consequences about, i.e. which measures and courses of action have been taken into account and were implemented in order to improve or to resolve the risky situation, respectively?

Impeding factors with respect to the acceptance, maintenance, and success of CIRS.

Promotional factors with respect to the acceptance, maintenance, and success of CIRS.

Relationship between CIRS and its impact on patient safety.

Useful supplements on CIRS.

After application of the selection criteria, 36 studies (Table 2 ), 6 textbooks (Table 3 ), and 14 technical reports (Table 4 ) for data synthesis and analysis came under scrutiny.

Most articles deal with the implementation and utilization of incident-reporting systems. Therefore, organizational culture, clinical staff, and safety issues play a major role in explanation of merits and demerits of CIRS and related reporting systems.

Many authors [ 5 , 6 ] stated that incident-reporting systems capture only a small fraction of occurring incidents in hospitals. Reasons for non-reporting of errors are a lack of feedback, a lack of knowledge, time pressure, and underestimation of the critical incident (CI) [ 7 ]. It was found that a high incident-reporting rate correlates with a sound error and safety culture [ 8 ]. Another problem is the quality and validity of the incidents reports: CIRS indices are often skewed and ambiguous [ 9 ] or the information is often too generic [ 10 ]. To collect incident reports without in-depth analysis does not lead to a higher level of patient safety [ 11 ].

Incidents are prevalent in hospitals and can be found in nearly all clinical areas and operations. A field study from Switzerland [ 4 ] revealed that nearly half of all documented incidents (number ( N ) = 1.470) are human errors (49.5%). Other incidents can be ascribed to organizational settings (24.9%), infrastructure and environment (10.8%), and technical problems (6.2%), amongst others (8.6%). Another field study conducted in Italy and Romania [ 12 ] yielded the following results: in a hospital in Bucharest (Romania), most incident reports related to diagnostics (28%), surgery (14%), and patient falls (12%). In Genoa (Italy), patient falls (32%), incidents by nursing (20%), and incidents in diagnostics (19%) were reported, whereas in Milan (Italy), incidents by nursing (25%) and medication regulation and administration (21%) and incidents in diagnostic procedures (17%) can be found. A Japanese study [ 13 ] showed that most reports were based on medication errors (2815 reports, 46.6% of a total of 6041 reports), followed by complications and errors with medical stock (1.147 errors, 19.0%), and errors with patient falls (826, 13.7%). Here, the high number of reports was ascribed to an underdeveloped communication policy. A German analysis of 151 incidents [ 14 ] yielded the following results: 71 errors (47%) based on organizational and communication errors, 54 reports (35.8%) as a result of human errors, and technical errors (17 reports, 11.3%), amongst others (9 reports, 5.9%). Most errors were found in medication (29%), followed by patient falls (14%) and medical operations (15%) [ 15 ]. The authors stated that 59% of all reported errors can be classified as preventable [ 14 ].

The occurrence of incidents with respect to organization and processes [ 16 , 17 ], surgery and anaesthesia [ 18 , 19 , 20 ], and medication [ 6 , 20 , 21 , 22 , 23 , 24 , 25 ] were described, too.

Although CIRS reports stem from very different clinical areas, i.e. theatre, ICU, patient falls, nursing care, and medication vide supra, CIRS and related voluntary reporting systems are predominantly used by nursery staff whereas it is rarely used by other clinical staff members, in particular physicians [ 7 , 18 , 26 , 27 ]. In one case, it was found that physicians reported adverse events mostly via the clinical risk management, while nursing staff used more often CIRS settings [ 26 ]. This observation may reflect the reluctance of clinical professionals to internalize the necessity of an error culture [ 28 ]. In order to remedy these shortcomings, the promotion of a voluntary involvement of physicians was highly recommended [ 15 ]. Anyway, many authors suggest that the success of incident-reporting systems depend on whether it is regarded as a holistic approach, i.e. CIRS must integrate into the organizational processes of the health care system [ 29 , 30 , 31 , 32 , 33 ] and even necessitates the commitment of top management [ 34 ].

Different studies illustrate that the handling of CIRS depends on the kind of occupants and the medical discipline. A study [ 13 ] stated that the majority of reports are generated by nurses using their own CIRS paper form. Conversely, the medical profession reports preferentially clear errors. In a European study [ 27 ], about 30% of the CIRS reports ( N  = 226) stemmed from nursing personnel, about 15% from medical professionals, and about 24% from medical-technical service staff. These results are consistent with those from [ 35 ]. An analysis of different medical disciplines illustrates that mainly anaesthesia and surgical care staff use CIRS (37%) [ 15 ]. Another source [ 18 ] revealed that mainly anaesthesia and surgical care staff report errors (37%), followed by ward nurses (31%), medical professionals (17%), and administrative staff document errors (5%). Similar results were described in a comparative study of the hospital from New York, Utah, and Colorado [ 15 ]. Here, 3407 (88%) errors of all registered notifications were reported by the nursing staff, 73 reports (1.9%) by physicians, and 346 reports (8.9%) by other staff. About 50% (1859) of all CIRS reports were submitted by the patient ward , 797 (21%) from the intensive care units, 544 (14%) from surgery, and less than 5% from other areas. Other authors [ 15 ] confirmed that the minority of CIRS will be generated by medical professionals. As a consequence, they called for a more active collaboration to increase the effectiveness of reporting systems in hospitals [ 15 ].

Documented improvement action

The study of Rose and Hess [ 36 ] showed that 585 suggestions for improvement were implemented from a total of 5000 CIRS reports, although it was found that processes and measures might generate new errors. Therefore, an effective error management has to be implemented in addition to the CIRS system. In two studies, acquisition of new equipment, improvements in medication and administration, adoption of novel standards, and training programs amongst other measures were implemented as a result of incident reports [ 10 , 37 ]. The training of staff was recommended by most authors. The utilization of incentives (establishment of a ‘Good Catch Award’) was proposed by Herzer et al. [ 38 ]. Hübler et al. [ 17 ] gave recommendations in terms of surgery and anaesthesia.

Obstructive and assisting aspects

Several factors detrimental to a well-functioning CIRS can be identified: work overload (a higher workload has a negative effect on safety [ 39 ] and/or time pressure [ 7 ]), untrained staff (ignorance or lack of knowledge amongst staff members) [ 5 , 13 , 17 , 40 ], lack of feedback, lack of communication and/or team work [ 17 ], a poor quality of incident reports (inconclusive statements or too generic data) [ 9 , 10 ], and the collection of incident reports without an in-depth analysis [ 11 ]. During the implementation phase of a reporting system, resentments amongst staff members which affect the acceptance of CIRS might arise [ 41 ]. With respect to the validity of the report error data and information, this can primarily be attributed to the profession [ 42 ]. Other issues were discussed in greater detail: anonymity and consequences [ 4 ], provisions and time [ 8 , 18 , 32 ], and feedback [ 7 , 43 ].

Many authors wrote about factors that can positively affect the acceptance and effectiveness of CIRS. First of all, professional leadership is indispensable for the implementation and application of an efficient CIRS. This can be attributed to a company-specific authority and the role model function. Leadership must accept an open error-reporting culture for the safety and benefit of patients. One element is to ensure and promote effective work at all levels to increase patient safety. These can be mediated by education and training to increase the knowledge and skills of the staff [ 25 , 27 , 30 ]. Another aspect is the implementation of a “no blame” error and feedback culture and the security of an absolutely anonymous reporting system [ 4 , 37 , 41 , 44 ]. Similarly, transparency, trust, and knowledge on CIRS are mandatory and are closely related to the training and skills of clinical staff [ 4 , 14 , 45 , 46 , 47 ]. In addition, feedback was identified as an essential part of CIRS [ 4 , 13 , 43 , 44 , 46 ].

Some features and criteria of an effective CIRS process [ 11 , 36 ] and generic positive factors of CIRS [ 13 , 16 ] were described in detail, too.

CIRS and positive trends

In a survey [ 27 ], 100% of medical professionals and 100% of nurses specified sustainable corrections for their organization based on CIRS reports, whereas 50% of the medical-technical staff indicated no improvements due to CIRS. It was found that CIRS is important in creating a positive error-safety culture, in detecting weak points, and in analysing necessary system changes [ 27 ]. CIRS can provide sufficient qualitative data for detecting critical system errors in health care institutions and organizations. The CIRS-based data allows the analysis of the current situation and development of possible counterstrategies to positively influence the increase in patient safety [ 6 ]. In an Australian study, it was found that system changes based on CIRS reduce the numbers of future adverse events [ 48 ]. Other positive trends were described elsewhere [ 49 , 50 , 51 ]. Certain measures were given by Leape and Berwick [ 2 ] and Merkle [ 29 ].

Further cognition

Several issues of further importance were found: (i) technical measures derived from incident reports may lead to new error resources [ 50 ]; (ii) the probable importance of national incident-reporting systems relevant to anaesthesia [ 31 ]; (iii) an inflationary push of CI-reporting systems without a sound comprehension or planning (see Ramanujam et al. [ 30 ] for an example in medication); (iv) ineffectiveness in dealing with CI reports [ 4 ]; (v) the relationship between CIRS and related reporting systems with organizational quality management [ 52 ]; (vi) complementary approaches of CIRS [ 5 , 6 , 8 , 16 , 26 ]; and (vii) the dispute on the relationship between incident report frequency and patient safety [ 8 , 12 , 15 , 17 , 18 , 20 , 21 , 25 , 53 ].

In recent years, CIRS and related reporting systems (there are three distinct reporting systems in European hospitals, at least: Doupi [ 54 ]) have become an essential prerequisite for many health care organizations [ 54 ]. The implementation of CIRS is an important undertaking for hospitals as it is expected to contribute significantly to the reduction of clinical risk. With respect to Austria, the integration of risk management in quality management systems (ISO 9001:2015) and in the national law of Austria ( Ministerialentwurf 143/ME XXV, §4 (15)) necessitates the development of consistent risk management practices in clinical settings.

The purpose of this work was a literature search to provide an overview on CIRS and its utility in clinical risk management and the relationship between CIRS adoption and patient safety. Application of predetermined exclusion criteria and inclusion criteria led to a core set of articles consisting of 36 studies, 6 reviews, and 14 specialist books or technical contributions. Available data confirm a positive relationship between the utilization of CIRS and an increase in patient safety. A ‘probable’ positive effect of incident reporting on patient safety was established, but CIRS must be planned and implemented in a systematic way.

Core elements of a well-functioning CIRS are feedback, involvement of the whole staff including top management commitment, and the integration of CIRS in both risk and quality management. It is important to illustrate the advantages of a CIRS system for a transparent risk reduction process for the benefit of the patients (and, of course, for the clinical staff at all hierarchical levels).

Anonymity and incentives play a pivotal role in maintaining incident reporting, too. Training of staff and transparency are very often mentioned throughout the sources which came under scrutiny. A well-planned and implemented CIRS may improve organizational error-reporting culture, learning processes, and overall safety. In practical terms, the establishment of a skilled risk manager position is highly recommended to point out the importance of CIRS and to encourage recognition and acceptance for a successful CIRS implementation. The risk manager has to find ways to convince members of the top management and clinical staff members to contribute to risk minimization and patient safety through CI reporting. Conversely, the risk manager needs the support of top management.

A CIRS not supported by managers of the higher organizational levels will be implemented with trouble and will not produce any quantifiable improvement. It should be also noted that key figures or indicators, which can be often found in literature on CIRS, are probably helpful in terms of process steering in health care organizations, but do not improve patient safety.

In addition, several limitations have been found:

Because of the chosen method, there may be restrictions in validity imposed by the selection criteria and by the restricted number of pages.

There are no pooled results due to the non-availability of intervention studies as a result of the predetermined selection criteria.

Due to the heterogeneity of incident-reporting systems and the inclusion of similar designations such as near misses and CI, interpretations in literature reports often diverge.

Because no fee-based databases were used in the literature search, there might be further restrictions in validity.

There is an unmet need for a confirmation of the effectiveness of CIRS in clinical practice. This would provide another starting point for a Ph.D. thesis.

The literature search conducted in this study revealed unambiguously that incident reporting in hospitals is highly variable. This can be attributed to the non-availability of a global standard, norm, or certification guidance specific for CI. In practical terms, it seems that CIRS (or similar reporting systems as seen in Doupi [ 54 ] and in Levtzion-Korach et al. [ 26 ]) is often implemented in a more intuitive manner instead of in a systematic way. Nevertheless, CIRS was found to have a positive impact on safety culture in most cases, although description or analysis of the factual relationship between the reporting system and patient safety remains vague. When applied in an optimized manner, CIRS induces positive changes such as the adaption of processes [ 20 , 53 ], awareness of risk [ 10 , 16 , 19 , 53 ], and ‘near misses’ [ 19 , 20 ].

Abbreviations

Critical incident(s)

• Critical Incident Reporting System

Intensive care unit

Number (statistics)

Standard operating procedure

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Petschnig, W., Haslinger-Baumann, E. Critical Incident Reporting System (CIRS): a fundamental component of risk management in health care systems to enhance patient safety. Saf Health 3 , 9 (2017). https://doi.org/10.1186/s40886-017-0060-y

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The importance of incident reporting in nursing

Table of contents

What is the purpose of an incident report in nursing?

The purpose of an incident report in nursing is multifaceted and crucial for both patient safety and quality improvement as well as legal documentation. In this article we’ll tell you all about incident reporting in nursing. About the importance, who’s responsibility it is to fill out a form and when incidents should be reported. We’ll conclude the article with an example.

Why is reporting important for nurses?

Overall, incident management plays a vital role in promoting patient safety , quality of care, and professional accountability within nursing and healthcare settings. Here are some key reasons for its importance:

• Quality Improvement : Incident reports help healthcare organizations identify patterns or trends in patient safety issues. Analyzing these reports allows for the implementation of corrective actions, process improvements, and training initiatives to prevent similar incidents from happening in the future.
• Risk Management : By documenting incidents, nursing organizations can assess risks and develop strategies to reduce them.
• Documentation : Incident reports provide a formal record of any incident, error, or near-miss that occurs during patient care. This documentation is vital for legal purposes, risk management, and compliance with regulatory requirements.
• Legal Protection : In the event of litigation or complaints, incident reports serve as legal documentation of the actions taken by nursing professionals. They provide a clear account of the incident, the steps taken to address it, and any follow-up actions, which can help protect both the healthcare provider and the organization legally.
• Learning and Education : Incident reports contribute to a culture of learning and continuous improvement within healthcare organizations. By encouraging staff to report incidents without fear of blame or retribution, organizations can foster an environment where lessons are learned from mistakes and shared across the team.

Who should be writing an incident report in nursing?

In nursing, incident reports are typically written by the healthcare professionals directly involved in or witnessing the incident. This may include nurses, physicians, nursing assistants, or any other staff members who were present during the incident.

The person responsible for writing the incident report should be someone who can provide accurate and detailed and factual information about what happened. Additionally, they should document any actions taken following the incident, such as interventions, notifications, or changes in patient care plans.

When should incidents be reported in nursing?

The specific timing for reporting incidents may vary depending on the policies and procedures of the nursing facility, but generally, incidents should be reported immediately or as soon as the nurse or healthcare professional becomes aware of them. This ensures that relevant information is documented while it is still fresh in the minds of those involved and allows for timely investigation and follow-up.

By reporting incidents promptly, healthcare providers can work together to address any issues, implement corrective actions, and prevent similar incidents from occurring in the future, ultimately ensuring the safety and well-being of patients.

List of reportable incidents in nursing homes

Identifying what qualifies as an incident can sometimes be challenging. Some examples of incidents in nursing homes that should be reported promptly include:

• Resident falls resulting in injury, or without injury but with a change in condition
• Medication errors, including wrong medication, wrong dosage, or missed doses
• Adverse reactions to medications or treatments
• Resident abuse or neglect, including physical, verbal, emotional, or financial abuse
• Resident wandering off unsupervised
• Any significant change in a resident's condition, including sudden decline in health status
• Unexplained injuries or bruises

Nursing incident report guidelines

Incident reports include factual details such as the date, time, and location of the incident. In addition a description of what happened should be added as well as any actions taken in response to the incident, and follow-up measures to address the issue. The primary purposes of incident reports in nursing facilities are:

• Documentation : Providing a comprehensive record of incident occurrences, ensuring all relevant information is reported accurately.
• Analysis : Enabling investigation and examination of incidents to uncover root causes, contributing factors, and ways for improvement.
• Prevention : To help develop and implement preventive actions and measures aimed at reducing the risk of similar incidents in the future.
• Communication : To communicate important information about incidents to relevant stakeholders, including hospital administrators, healthcare providers, and regulatory agencies.

Example of a nursing incident report

Incident Report

Date : March 12, 2024 Time : 10:30 AM Location : Willow Grove Nursing Home, Room 214 Reporter : Jane Doe, RN

Incident Details : At approximately 10:15 AM, while conducting morning rounds, I entered Room 214 to check on Mr. John Smith, a 78-year-old resident. Upon entering the room, I noticed that Mr. Smith was lying on the floor next to his bed, holding his left arm and grimacing in pain.

Witnesses : None present at the time of the incident.

Description of Incident: Upon closer inspection, it was evident that Mr. Smith had sustained a fall. He complained of pain in his left arm and was unable to move it without discomfort. Vital signs were stable, with no signs of head trauma or significant injuries observed.

Actions Taken:

• Immediately assisted Mr. Smith back onto his bed using a transfer lift to ensure safety and minimize further injury.
• Conducted a thorough assessment of Mr. Smith's injuries, focusing on his left arm. Observed swelling and tenderness around the elbow joint.
• Administered pain relief medication (acetaminophen 500 mg) as ordered by the physician to alleviate discomfort.
• Notified the attending physician, Dr. Emily Johnson, of the incident and Mr. Smith's condition.
• Completed documentation in the resident's medical chart, including details of the fall, assessment findings, interventions, and physician notification.
• Implemented fall prevention measures, including adjusting the bed height and ensuring the call bell was within Mr. Smith's reach.
• Informed the charge nurse and nursing supervisor of the incident for further review and follow-up.

Follow-up Actions:

• Scheduled an X-ray of Mr. Smith's left arm to rule out any fractures or underlying injuries.
• Notified Mr. Smith's family members of the incident and his current condition.
• Implemented additional monitoring of Mr. Smith's mobility and safety precautions to prevent future falls.
• Conducted a review of Mr. Smith's care plan to identify any necessary adjustments or interventions to minimize fall risk.

Signature of Reporter : [Jane Doe, RN] Date and Time of Report Completion : March 12, 2024, 11:00 AM

Incident reporting software

By implementing reporting software , nursing organizations are better equipped to document and analyze incidents. Software tools make it possible to collect data on a larger scale which helps to identify trends. Gaining insights in these trends makes it easier to start making positive changes that benefit patient safety and quality improvements. That is the exact purpose of incident reporting.

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• Volume 4, Issue 1
• Improving reporting of critical incidents through education and involvement.
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• Peter Donnelly
• Belfast Health & Social Care Trust.
• Correspondence to Peter Donnelly pdonnelly00{at}hotmail.com

Critical incident reporting involves highlighting events and near-misses which have a potential impact on patient care and patient safety. Reporting of critical incidents is a recognised tool in improving patient safety. Within the community paediatric setting in the Belfast Health & Social Care Trust (BHSCT) there is a paucity of incident report forms. The purpose of this quality improvement project was to establish the barriers to reporting critical incidents and to implement plan-do-study-act (PDSA) cycles to create a climate for change.

The methodology for this project was to firstly perform a baseline audit to review all submitted critical incident reports for the Community Paediatric team in the BHSCT for a six month period. A questionnaire was distributed to staff within the multidisciplinary team to establish examples of barriers to reporting. Interventions performed included introducing an agreed definition of a critical incident, distributing/presenting questionnaire findings to senior members of the various management teams and providing feedback to healthcare workers after presentation of a critical incident presentation. A review of incident reports was performed over the subsequent six month period to assess how the interventions impacted on incident reporting.

Over 12 questionnaires 28 barriers to reporting critical incidents were reported which fell into five separate categories. Staff members were twice as likely to report negativity after reporting a critical incident. Overall critical incident reporting within the BHSCT Community Paediatric team improved from 11 incident reports (1.8 per month) to 22 incident reports (3.7 per month) after completion of the quality improvement project. This represents an increase of 100%.

This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits use, distribution, and reproduction in any medium, provided the original work is properly cited, the use is non commercial and is otherwise in compliance with the license. See:

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https://doi.org/10.1136/bmjquality.u206996.w3776

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The Community Paediatric Team in BHSCT-Northern Ireland carried out a review of incident reports for the period of February to August 2014. The purpose of this review was to identify areas for improvement and to enable the development of various quality improvement projects. A baseline audit was performed reviewing the incident reports submitted electronically for this period. This review identified a total of eleven incident reports. The peak month for incident reporting was March.

Due to the paucity of incident reports it was difficult to highlight a specific shortfall in practice in order to design a quality improvement project. As a result of this review it was decided to perform a quality improvement project to encourage incident reporting.

One Cochrane Review analysed four separate studies with the aim of reviewing interventions designed to increase clinical incident reporting in healthcare settings 1. This study reviewed the implementation of different reporting systems and found mixed results. The conclusion of this study found that it was 'not possible to draw conclusions for clinical practice'.

This quality improvement project differs as it does not rely on the introduction of a new reporting system but rather to create improvements within an established system.

As a result of this review it was decided to conduct a quality improvement project aiming to improve the use of an existing system through education and feedback, exploring facilitators and barriers which may or may not include acceptability of the reporting systems. The author of this quality improvement was unable to find any research specific to incident reporting within the community paediatric population.

Baseline measurement

For this project incident reports were reviewed from a database of incident reports submitted via an online reporting system used within the BHSCT. Exclusion criteria confined the search to the community paediatric sites within the BHSCT and subsequently highlighted 21 incident reports between December 2012 and August 2014. Further exclusion criteria was then applied to include only those forms submitted over a six month period between February and August 2014. This highlighted a total of 11 forms over a six month period. The 11 incident reports were further subdivided into the following categories; appointments (n=1), consent/confidentiality (n=1), patient information (n=6), IT/Infrastructure (n=2), Other (n=1).

A driver diagram was constructed to address how to approach improving incident reporting. Primary drivers identified for this project included a review of the definition of a critical incident and improving the culture of reporting through staff education and involvement. Secondary drivers included reviewing local policy and the literature to identify an agreed definition. A staff questionnaire was designed to identify barriers to incident reporting and to give an overview of staff awareness and the education that may be needed to improve incident reporting. The alteration of the system for reporting incidents was outside the remit for this project.

Clarifying an agreed definition of a critical incident was the starting intervention. It was felt that this would provide a sense of clarity in explaining the purpose of the project. This also opened up discussion amongst the community paediatric team and started the process of raising awareness and providing education.

The staff questionnaire facilitated fact finding among various mutidisciplinary team members. This qualitative method was used to explore facilitators and barriers to incident reporting. This questionnaire also highlighted educational shortfalls within various departments which were relayed to senior management as one of the PDSA cycles.

It is hoped that exploring barriers to change will facilitate the introduction of interventions that will create a climate for change and the resulting change in ethos will lead to sustainable improvement.

PDSA Cycle 1. A literature review was performed to establish an agreed definition of a critical incident. Information came from various sources including other hospital trusts and the Royal College of Anaesthetists. The Belfast Trust was also contacted to supply an agreed definition. These definitions were discussed among the paediatric team and an agreed definition was agreed.

PDSA Cycle 2. A qualitative questionnaire was designed. The questionnaire was distributed amongst the multidisciplinary team within community paediatrics. The areas covered by the questionnaire included experience of reporting, use of the online reporting system, barriers to reporting, and feedback. This PDSA cycle provided the information for the subsequent PDSA cycle.

PDSA Cycle 3: Information leaflets and posters were introduced on notice boards as a further intervention. These posters gave team members instructions on how to use and access the incident reporting system. The purpose of this PDSA cycle was to address one of the barriers to reporting - 'unfamiliar with the reporting system'. Four of ten questionnaire respondents had identified this as a barrier to reporting.

PDSA Cycle 4. A critical incident reporting presentation was given to the management team and senior clinical team members of the multidisciplinary team. Junior medical staff were also present. Information from this presentation was filtered through to junior colleagues within the multidisciplinary team ensuring all members of the team were fully informed of the findings. This presentation addressed attitudes and suggestions for improvement. Presenting data by itself was able to raise awareness of the issue of poor reporting.

PDSA Cycle 5: One of the main findings of the questionnaire was that team members did not receive feedback (eight of ten questionnaire respondents). Seven of the ten respondents reported they would like to receive feedback. To address this barrier to reporting increased emphasis was placed on providing feedback. This feedback was provided in the form of regular team meetings chaired by the Children's Network Manager for Community Paediatrics. At these meetings every incident report (including actions) are discussed. To ensure involvement with the multidisciplinary team and junior colleagues the minutes from these meetings were circulated to all staff. The purpose of this intervention was three-fold. Firstly to provide the feedback requested by the questionnaire respondents and secondly to address respondents concerns that completing incident reports was 'just another paper exercise'. The provision of subsequent actions taken after review of incident forms was an intervention aimed to address staff members apathy to incident reporting. This was highlighted as a key barrier to reporting.

PDSA Cycle 6: It was clear that education and involvement is key to improving incident reporting. To facilitate this the senior members of the multidisciplinary team set out to ensure 100% of staff have received training on the use of the incident reporting system. This intervention consisted of a short training session and aimed to address the fact that eight questionnaire respondents had reported not receiving any training at the beginning of this project. Having training on the reporting system will help ease the process of completing the incident form and address the barrier to reporting of 'time pressures'.

Incident reports were reviewed subsequent to the interventions over a six month period to allow comparison with the previous time period. As previously mentioned eleven incident reports were submitted from February to August 2014. Only two reports were submitted over the latter three months.

Incident reporting largely improved during the course of this quality improvement project. In August only one incident report was submitted. During this month the BHSCT definition of a critical incident was agreed upon for use within the Community Paediatric Setting (PDSA cycle 1).

The agreed definition from the Belfast Health and Social Care trust was " Any event or circumstance that could have or did lead to harm, loss or damage to people, property, environment, or reputation."

A staff questionnaire was distributed in September 2014 (PDSA cycle 2).

In total 12 questionnaires were returned from specialties including physicians, occupational therapists, speech and language therapists, and nursing colleagues. Only four staff members reported observing a critical incident over the previous three months, three of whom submitted an incident report. This information tallies with the audit data which highlighted one incident report for each of the preceding three months. Of the three staff members who reported submitting incident forms, two reported feeling negative afterwards. One staff member felt 'unsure' and a second felt 'worried others would get in trouble'. Only one of the staff members reported feeling positively about submitting an incident report writing when she wrote 'I had done my job'. Two of the twelve questionnaire respondents revealed they were unaware of the online reporting system and half of respondents revealed they had never used it. This suggests that the majority of incident reports are being completed by a minority of staff. Awareness of the reporting system was targeted through the introduction of posters in staff areas (PDSA cycle 3) and also through ensuring all staff were trained in the use of completing incident reports (PDSA Cycle 6).

Eight members of staff revealed they had not had training on the use of the reporting system - this was a key part of the fourth PDSA cycle when feedback was given to senior colleagues and also PDSA cycle 6.

In terms of barriers to incident reporting there were 28 barriers selected within the 12 forms. These reasons can be divided into five categories as follows: time pressures (n=9), unsure of what constitutes a critical incident (n=7), apathy about reporting (n=5), unfamiliar with the reporting system (n=4), and scared of getting someone in trouble (n=3). Eight respondents reported never receiving feedback from incident reports. Seven respondents specifically commented that feedback on incident reports would be of benefit to improve patient care in the future. As a result of these barriers we implemented tests of change to address staff concerns. Ensuring staff members were trained on the use of the reporting system facilitated educating staff on how to complete the incident report in a timely manner - thereby addressing time pressures, as well as ensuring staff members were now familiar with the reporting system itself. The education session also explained what constitutes a critical incident as determined by our agreed definition (PDSA cycle 1). Apathy on incident reporting was addressed by providing regular feedback. This feedback was facilitated by PDSA cycle 5 whereby regular feedback of incident reports and subsequent actions was provided.

The agreed definition of a critical incident (PDSA cycle 1) was completed in August 2014. Following completion of the questionnaire during September (PDSA cycle 2) the number of incident reports increased to seven. This is felt to be a direct effect of increased awareness and education surrounding incident reporting. In October the level of incident reporting was sustained at five reports. Posters were positioned in staff areas at this time (PDSA cycle 3). There was concern regarding sustainability of results over November and December (two reports and three reports respectively) and as a result of this a feedback presentation was given in January 2015 (PDSA cycle 4). This presentation outlined earlier provided feedback and education to management and senior colleagues facilitating dissemination to junior staff. This presentation halted the decline of incident reporting and the number of incident reports submitted was maintained at three for that month. It is important to note that the incident report itself was not adjusted in the course of this project as it was an agreed form already approved for use within the Trust. The purpose of this project was to facilitate improved compliance with the existing system.

PDSA Cycles 5 and 6 were long term tests of change and have aimed to provide long term ongoing education to the multidisciplinary team. Addressing staff training was completed in February 2015 after making senior multidisciplinary team members aware that staff had reported a lack of training in incident reporting. These PDSA cycles are long term strategies to improve reporting and as such have not provided a rapid increase in incident reporting. They make be considered unsuccessful PDSA cycles as they have not improved incident reporting however the aim of these interventions is to provide a longer term climate for change.

Each PDSA cycle was implemented with varying degrees of success in terms of improving incident reporting, however, in total 22 incident reports were submitted over the six months from August 2014 to February 2015. This represents an increase of 100% and shows that this quality improvement project has resulted in a global improvement.

See supplementary file: ds5601.png - “A run diagram showing the number of incidents reported during the project.”

Lessons and limitations

We learnt a lot of lessons during this project. It was interesting to read variations of a definition of a critical incident. It was certainly felt to be beneficial to highlight an agreed definition for future use within community paediatrics.

The main challenge faced during this project was regarding addressing apathy among the multidisciplinary team. Questionnaires were slow to be returned and this was encouraged via email reminders and personal request. In the future it would be of benefit to have an increased return of questionnaires to provide more suggestions for improvement however in terms of qualitative data we achieved an acceptable response rate.

The main limitation of this study is the short study period. Although incidents were reviewed over a considerable period it is perhaps optimistic to expect a change in ethos across a large range of health care professionals and across a range of sites in a health care trust. Sustainability can only be achieved through involvement of senior colleagues and that was the purpose behind our third PDSA cycle. Junior colleagues rotate into different clinical areas after a six month period and this can also impact on sustainability.

This quality improvement project has resulted in increased reporting of critical incidents. This paves the way for future quality improvement projects to be performed targeting areas of concern which will help improve patient safety across various disciplines.

Anecdotally the multidisciplinary team report being more confident in reporting critical incidents. This anecdotal evidence was evaluated further by completion of a post-project questionnaire. This questionnaire was completed by 10 members of the multidisciplinary team. A Likert scale was used during this questionnaire and established that eight questionnaire respondents 'strongly agreed' that they now felt more confident in reporting critical incidents. In addition to this seven questionnaire respondents felt they were now 'more aware of what constitutes a critical incident'. This shows that members of the multidisciplinary team have had benefit from this quality improvement project. Senior colleagues have taken useful information back to their various departments to ensure all staff are trained in reporting incidents using the current reporting system. It is clear from reviewing barriers to reporting that time constraints is a significant concern for those who complete incident forms however with experience of the system this may improve. There are barriers and difficulties with every reporting system and we must ensure staff are aware of the obligation to report incidents to facilitate a climate for change and improvement in patient safety.

It is difficult to assess the scale of improvement over a short period of time however it is hoped that leadership from senior colleagues will be of benefit in achieving sustainability.

Parmelli E, Flodgren G, Fraser SG et al.Interventions to increase clinical incident reporting in health care.Cochrane Database Syst Rev. Author manuscript; available in PMC 2014 September 22. Published in final edited form as: Cochrane Database Syst Rev. 2012; 8: CD005609. Published online 2012 August 15.

Declaration of interests

Nothing to declare

Acknowledgements

Dr J Bothwell, Dr M McGinn, Dr M Stewart, Dr K Stevenson, Mr K McKeever, The Community Paediatric Team BHSCT

Ethical approval

This project was deemed an improvement study and not a study on human subjects, and ethical approval was not required.

Supplementary materials

Supplementary material for improving reporting of critical incidents through education and involvement..

Extra information supplied by the author

• A run diagram showing the number of incidents reported during the project.

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Critical incidents, crucial issues: insights into the working lives of registered nurses

Affiliation.

• 1 Institute of Health Studies, University of Plymouth, Taunton.
• PMID: 9188351

The critical incident technique has been used in nursing in a number of ways: in developing understanding of the nursing role, as a quality assurance strategy, as an assessment and evaluation tool, and as an aid in the fostering of reflective practice. This article describes how the technique, used as a theoretical course assessment for a group of students studying long ENB courses, could be used to shed light upon issues regarded as crucial in the daily working lives of this group of registered nurses, and upon the reflective skills which they were able to employ.

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