Commentary The frustrating case of incident-reporting systems. Citation Text: Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400-2. doi:10.1136/qshc.2008.029496. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Save Save to your library Print Share Facebook Twitter Linkedin Copy URL May 20, 2009 Shojania KG. Qual Saf Health Care. 2008;17(6):400-2. View more articles from the same authors. This commentary discusses the limitations of incident reporting systems and provides suggestions for how data gathered from incident reports may be used to improve safety. PubMed citation Available at Save Save to your library Print Share Facebook Twitter Linkedin Copy URL Cite Citation Citation Text: Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care. 2008;17(6):400-2. doi:10.1136/qshc.2008.029496. Copy Citation Format: DOIGoogle ScholarPubMedBibTeXEndNote X3 XMLEndNote 7 XMLEndnote taggedPubMedIdRIS Download Citation Related Resources From the Same Author(s) The elephant of patient safety: what you see depends on how you look. August 25, 2010 Deaths due to medical error: jumbo jets or just small propeller planes? August 8, 2012 Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021 Evidence-based medicine: a cornerstone for clinical care but not for quality improvement. May 15, 2019 Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021 Clinicians in quality improvement: a new career pathway in academic medicine. February 25, 2009 The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety. March 6, 2005 Estimating deaths due to medical error: the ongoing controversy and why it matters. October 26, 2016 Trends in adverse events over time: why are we not improving? March 27, 2013 'Bad apples': time to redefine as a type of systems problem? June 26, 2013 Root-cause analysis: swatting at mosquitoes versus draining the swamp. March 22, 2017 A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. February 15, 2017 Hospital mortality: when failure is not a good measure of success. July 30, 2008 Implementing patient safety interventions in your hospital: what to try and what to avoid. March 12, 2008 The vanishing nonforensic autopsy. March 12, 2008 'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. March 12, 2014 Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. January 12, 2022 Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? August 5, 2015 Quality improvement in medical education: current state and future directions. January 18, 2012 Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. March 25, 2020 Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. November 1, 2006 The tension between needing to improve care and knowing how to do it. August 15, 2007 Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. July 18, 2007 Patient safety at the crossroads. May 4, 2016 Improving patient safety: moving beyond the "hype" of medical errors. October 26, 2005 Vulnerability of the medical product supply chain: the wake-up call of COVID-19. November 25, 2020 Usability evaluation of order sets in a computerized provider order entry system. August 24, 2011 Does user-centred design affect the efficiency, usability and safety of CPOE order sets? May 4, 2011 Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. March 20, 2013 Safe but sound: patient safety meets evidence-based medicine. April 12, 2006 Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. July 10, 2019 Clinical problem-solving. Lost in transcription. October 18, 2006 Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. March 27, 2005 Teaching quality improvement and patient safety to trainees: a systematic review. June 30, 2010 Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. November 12, 2014 Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. August 29, 2007 Does full disclosure of medical errors affect malpractice liability? The jury is still out. March 6, 2005 Effect of point-of-care computer reminders on physician behaviour: a systematic review. March 24, 2010 Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory. September 11, 2013 Do physicians clean their hands? Insights from a covert observational study. July 27, 2016 Introducing the patient safety professional: why, what, who, how, and where? September 28, 2011 A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. September 24, 2014 Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. January 2, 2008 Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. June 22, 2022 The effects of on-screen, point of care computer reminders on processes and outcomes of care. September 2, 2009 Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011 Computerised provider order entry and residency education in an academic medical centre. August 1, 2012 Adverse events detected by clinical surveillance on an obstetric service. November 15, 2006 Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. January 31, 2024 Using prospective clinical surveillance to identify adverse events in hospital. March 30, 2011 Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort. July 15, 2015 Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. April 16, 2008 Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward. March 18, 2015 The many faces of error disclosure: a common set of elements and a definition. April 4, 2007 Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care October 2, 2019 Overestimation of clinical diagnostic performance caused by low necropsy rates. December 14, 2005 Temporal clustering of critical illness events on medical wards. July 26, 2023 Safe medication prescribing and monitoring in the outpatient setting. May 17, 2006 A systematic review of interventions to follow-up test results pending at discharge. February 7, 2018 What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. May 5, 2010 COVID-19: to be or not to be; that is the diagnostic question. July 8, 2020 The top patient safety strategies that can be encouraged for adoption now. March 13, 2013 Identifying medication errors in neonatal intensive care units: a two-center study December 4, 2019 Advancing the science of patient safety. May 25, 2011 Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. June 14, 2006 Patient safety and acute care medicine: lessons for the future, insights from the past. March 24, 2010 Are measurements of patient safety culture and adverse events valid and reliable? Results from a cross sectional study. July 8, 2015 Nontechnical skills in pediatric surgery: factors influencing operative performance. April 13, 2016 Nurse–patient ratios as a patient safety strategy: a systematic review. March 20, 2013 Unintended adverse consequences of a clinical decision support system: two cases. May 16, 2018 When there's no one to whom an error can be disclosed, how should an error be handled? August 14, 2019 Reducing emergency department charting and ordering errors with a room number watermark on the electronic medical record display. December 10, 2014 Nurse aides' ratings of the resident safety culture in nursing homes. September 27, 2006 Voluntary review of quality of care peer review for patient safety. May 23, 2007 Effective healthcare teams require effective team members: defining teamwork competencies. February 21, 2007 Five pitfalls in decisions about diagnosis and prescribing. November 2, 2005 Ethical duty of health care systems to address interfacility medical error discovery. October 17, 2018 How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients? April 19, 2006 Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. May 4, 2005 A case of adverse drug reaction induced by dispensing error. November 7, 2012 Confronting safety gaps across labor and delivery teams. January 15, 2014 Patient safety in surgery: non-technical aspects of safe surgical performance. April 7, 2010 The impact of electronic medical records data sources on an adverse drug event quality measure. March 17, 2010 Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. August 4, 2010 Design of an evidence-based "second victim" curriculum for nurse anesthetists. June 1, 2016 Preventing medication errors. August 10, 2016 Organising a manuscript reporting quality improvement or patient safety research. August 21, 2013 Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. April 17, 2013 The technologist's role in patient safety and quality in medical imaging. June 5, 2013 Reducing errors in emergency surgery. May 15, 2013 Effects of CPOE on provider cognitive workload: a randomized crossover trial. September 5, 2012 Can the aviation industry be useful in teaching oncology about safety? December 6, 2017 The systems approach to medicine: controversy and misconceptions. September 3, 2014 Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. May 20, 2009 Improving diagnostic decision support through deliberate reflection: a proposal. November 9, 2022 How should clinicians minimize bias when responding to suspicions about child abuse? February 22, 2023 From box ticking to the black box: the evolution of operating room safety. September 4, 2019 Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study. April 1, 2020 Human factors engineering in healthcare systems: the problem of human error and accident management. January 21, 2009 Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues. July 25, 2007 View More Related Resources Adopting high reliability organization principles to lead a large scale clinical transformation. April 26, 2023 Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach. April 19, 2023 A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. January 18, 2023 Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. November 16, 2022 The impact of COVID-19 workflow changes on radiation oncology incident reporting. November 2, 2022 Adverse event and complication tracking in anaesthesiology: dependence on self-reporting despite implementation of electronic health records. March 16, 2022 Preventing and mitigating radiology system failures: a guide to disaster planning. February 2, 2022 Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021 Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021 Reporting of unsafe conditions at an academic women and children's hospital. September 29, 2021 Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home. February 17, 2021 Assessing adverse events after chiropractic care at a chiropractic teaching clinic: an active-surveillance pilot study. November 4, 2020 Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. October 28, 2020 Operational measurement of diagnostic safety: state of the science. October 7, 2020 COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada. September 30, 2020 Why accountability sharing in health care organizational cultures means patients are probably safer. September 23, 2020 COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected. August 19, 2020 COVID-19 pandemic: a time for collaboration and a unified global health front. August 12, 2020 The next step in learning from sentinel events in healthcare. April 15, 2020 Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. October 16, 2019 From box ticking to the black box: the evolution of operating room safety. September 4, 2019 Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC). May 15, 2019 Evidence-based medicine: a cornerstone for clinical care but not for quality improvement. May 15, 2019 An IDEA: safety training to improve critical thinking by individuals and teams. April 10, 2019 Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. January 23, 2019 Silent witnesses: faculty reluctance to report medical students' professionalism lapses. November 28, 2018 Implementing safety hotlines: Stamford Health's experience and future opportunities. September 19, 2018 Factors influencing the reporting of adverse medical device events: qualitative interviews with physicians about higher risk implantable devices. March 7, 2018 Complications: acknowledging, managing, and coping with human error. November 1, 2017 Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. June 7, 2017 View More See More About The Topic Quality and Safety Professionals Error Reporting
Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021
Evidence-based medicine: a cornerstone for clinical care but not for quality improvement. May 15, 2019
Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021
The faces of errors: a case-based approach to educating providers, policy makers, and the public about patient safety. March 6, 2005
A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. February 15, 2017
Implementing patient safety interventions in your hospital: what to try and what to avoid. March 12, 2008
'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. March 12, 2014
Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. January 12, 2022
Temporal trends in patient safety in the Netherlands: reductions in preventable adverse events or the end of adverse events as a useful metric? August 5, 2015
Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. March 25, 2020
Graduate medical education and patient safety: a busy--and occasionally hazardous--intersection. November 1, 2006
Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. July 18, 2007
Medication reconciliation during transitions of care as a patient safety strategy: a systematic review. March 20, 2013
Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. July 10, 2019
Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. March 27, 2005
Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. November 12, 2014
Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. August 29, 2007
Does full disclosure of medical errors affect malpractice liability? The jury is still out. March 6, 2005
Effect of point-of-care computer reminders on physician behaviour: a systematic review. March 24, 2010
Sustaining quality improvement and patient safety training in graduate medical education: lessons from social theory. September 11, 2013
A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. September 24, 2014
Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis. January 2, 2008
Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. June 22, 2022
The effects of on-screen, point of care computer reminders on processes and outcomes of care. September 2, 2009
Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011
Computerised provider order entry and residency education in an academic medical centre. August 1, 2012
Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. January 31, 2024
Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort. July 15, 2015
Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. April 16, 2008
Application of a trigger tool in near real time to inform quality improvement activities: a prospective study in a general medicine ward. March 18, 2015
Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care October 2, 2019
A systematic review of interventions to follow-up test results pending at discharge. February 7, 2018
What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. May 5, 2010
Persistence of unsafe practice in everyday work: an exploration of organizational and psychological factors constraining safety in the operating room. June 14, 2006
Patient safety and acute care medicine: lessons for the future, insights from the past. March 24, 2010
Are measurements of patient safety culture and adverse events valid and reliable? Results from a cross sectional study. July 8, 2015
When there's no one to whom an error can be disclosed, how should an error be handled? August 14, 2019
Reducing emergency department charting and ordering errors with a room number watermark on the electronic medical record display. December 10, 2014
Effective healthcare teams require effective team members: defining teamwork competencies. February 21, 2007
Ethical duty of health care systems to address interfacility medical error discovery. October 17, 2018
How can the principles of complexity science be applied to improve the coordination of care for complex pediatric patients? April 19, 2006
Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. May 4, 2005
The impact of electronic medical records data sources on an adverse drug event quality measure. March 17, 2010
Comparing errors in ED computer-assisted vs conventional pediatric drug dosing and administration. August 4, 2010
Chemotherapy medication errors in a pediatric cancer treatment center: prospective characterization of error types and frequency and development of a quality improvement initiative to lower the error rate. April 17, 2013
Eight CT lessons that we learned the hard way: an analysis of current patterns of radiological error and discrepancy with particular emphasis on CT. May 20, 2009
How should clinicians minimize bias when responding to suspicions about child abuse? February 22, 2023
Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study. April 1, 2020
Human factors engineering in healthcare systems: the problem of human error and accident management. January 21, 2009
Impact of feeling responsible for adverse events on doctors' personal and professional lives: the importance of being open to criticism from colleagues. July 25, 2007
Adopting high reliability organization principles to lead a large scale clinical transformation. April 26, 2023
Quality improvement initiative to decrease central line-associated bloodstream infections during the COVID-19 pandemic: a "zero harm" approach. April 19, 2023
A multi-site assessment of inpatient safety event rates during the coronavirus disease 2019 pandemic. January 18, 2023
Toward zero harm: Mackenzie Health's journey toward becoming a high reliability organization and eliminating avoidable harm. November 16, 2022
Adverse event and complication tracking in anaesthesiology: dependence on self-reporting despite implementation of electronic health records. March 16, 2022
Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021
Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021
Adopting the Fall Tailoring Interventions for Patient Safety (TIPS) program to engage older adults in fall prevention in a nursing home. February 17, 2021
Assessing adverse events after chiropractic care at a chiropractic teaching clinic: an active-surveillance pilot study. November 4, 2020
Using event reports in real-time to identify and mitigate patient safety concerns during the COVID-19 pandemic. October 28, 2020
COVID-19 pandemic preparation: using simulation for systems-based learning to prepare the largest healthcare workforce and system in Canada. September 30, 2020
Why accountability sharing in health care organizational cultures means patients are probably safer. September 23, 2020
COVID-19 has united patients and providers against institutional betrayal in health care: a battle to be heard, believed, and protected. August 19, 2020
Adverse events in the operating room: definitions, prevalence, and characteristics. A systematic review. October 16, 2019
Standardising the classification of harm associated with medication errors: the Harm Associated with Medication Error Classification (HAMEC). May 15, 2019
Evidence-based medicine: a cornerstone for clinical care but not for quality improvement. May 15, 2019
Barriers to self-reporting patient safety incidents by paramedics: a mixed methods study. January 23, 2019
Silent witnesses: faculty reluctance to report medical students' professionalism lapses. November 28, 2018
Implementing safety hotlines: Stamford Health's experience and future opportunities. September 19, 2018
Factors influencing the reporting of adverse medical device events: qualitative interviews with physicians about higher risk implantable devices. March 7, 2018
Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. June 7, 2017