Comparing process- and outcome-oriented approaches to voluntary incident reporting in two hospitals.

Incident reporting (IR) systems serve as an important mechanism to understand, analyze, and potentially prevent errors in the hospital setting, though their utility has been questioned. This study categorized more than 2200 incident reports into whether they described aberrant care processes, undesirable outcomes, or both. Investigators found that 50% were only process-oriented and that these were more useful than solely outcome-oriented reports because the former helped identify preventability and relevant contributing factors. The authors advocate for hospitals to focus their IR systems on process-driven reports that encourage staff to highlight factors amenable to improvement interventions.