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. 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Striving for high reliability in healthcare: a qualitative study of the implementation of a hospital safety programme. June 22, 2022
Expanding the scope of Critical Care Rapid Response Teams: a feasible approach to identify adverse events. A prospective observational cohort. July 15, 2015
Looking back on the history of patient safety: an opportunity to reflect and ponder future challenges. November 3, 2021
Can SBAR be implemented with high fidelity and does it improve communication between healthcare workers? A systematic review. January 12, 2022
Incident reporting systems: what will it take to make them less frustrating and achieve anything useful? December 1, 2021
Grand rounds in methodology: key considerations for implementing machine learning solutions in quality improvement initiatives. January 31, 2024
Building the bridge to quality: an urgent call to integrate quality improvement and patient safety education with clinical care October 2, 2019
A primer on PDSA: executing plan–do–study–act cycles in practice, not just in name. February 15, 2017
Multiple interacting factors influence adherence, and outcomes associated with surgical safety checklists: a qualitative study. November 12, 2014
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
A qualitative analysis of physician perspectives on missed and delayed outpatient diagnosis: the focus on system-related factors. September 24, 2014
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
Putting out fires: a qualitative study exploring the use of patient complaints to drive improvement at three academic hospitals. July 10, 2019
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Effect of point-of-care computer reminders on physician behaviour: a systematic review. March 24, 2010
The effects of on-screen, point of care computer reminders on processes and outcomes of care. September 2, 2009
'I think we should just listen and get out': a qualitative exploration of views and experiences of Patient Safety Walkrounds. March 12, 2014
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Patient safety in emergency medical services: a systematic review of the literature. December 21, 2011
Identifying adverse events: reflections on an imperfect gold standard after 20 years of patient safety research. March 25, 2020
Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review. July 18, 2007
Combining ratings from multiple physician reviewers helped to overcome the uncertainty associated with adverse event classification. August 29, 2007
Use of an interactive, telephone-based self-management support program to identify adverse events among ambulatory diabetes patients. April 16, 2008
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Changes in rates of autopsy-detected diagnostic errors over time: a systematic review. March 27, 2005
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Does full disclosure of medical errors affect malpractice liability? The jury is still out. March 6, 2005
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Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. March 6, 2013
What happens between visits? Adverse and potential adverse events among a low-income, urban, ambulatory population with diabetes. May 5, 2010
A systematic review of interventions to follow-up test results pending at discharge. February 7, 2018
Clinical diagnoses vs. autopsy findings in early deceased septic patients in the intensive care: a retrospective cohort study. July 28, 2021
The influence that electronic prescribing has on medication errors and preventable adverse drug events: an interrupted time-series study. December 2, 2009
Medication errors: the impact of prescribing and transcribing errors on preventable harm in hospitalised patients. March 4, 2009
Reliability of the assessment of preventable adverse drug events in daily clinical practice. April 2, 2008
Design and implementation of an application and associated services to support interdisciplinary medication reconciliation efforts at an integrated healthcare delivery network. December 6, 2006
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Perceived disability-based discrimination in health care for children with medical complexity. July 19, 2023
The effect of structured medication review followed by face-to-face feedback to prescribers on adverse drug events recognition and prevention in older inpatients - a multicenter interrupted time series study. August 10, 2022
Temporal associations between EHR-derived workload, burnout, and errors: a prospective cohort study. July 20, 2022
Scaling up a diagnostic pause at the ICU-to-ward transition: an exploration of barriers and facilitators to implementation of the ICU-PAUSE handoff tool. September 27, 2023
Response of practicing chiropractors during the early phase of the COVID-19 pandemic: a descriptive report. July 8, 2020
Frequency and types of patient-reported errors in electronic health record ambulatory care notes. July 1, 2020
Computerised physician order entry-related medication errors: analysis of reported errors and vulnerability testing of current systems. January 28, 2015
SIMMEON-Prep study: SIMulation of Medication Errors in ONcology: prevention of antineoplastic preparation errors. December 17, 2014
The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: patient experiences, human factors, sedation, consent and medicolegal issues. November 12, 2014
Outcomes associated with the nationwide introduction of rapid response systems in the Netherlands. September 16, 2015
Voluntary medical incident reporting tool to improve physician reporting of medical errors in an emergency department. February 17, 2016
5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: protocol, methods, and analysis of data. September 24, 2014
Transforming communication and safety culture in intrapartum care: a multi-organization blueprint. June 3, 2015
Clinical impact and economic burden of hospital-acquired conditions following common surgical procedures. February 13, 2019
Patient and visitor aggression in healthcare: a survey exploring organisational safety culture and team efficacy. June 19, 2019
Characteristics of medical professional liability claims in patients with cardiovascular diseases. April 21, 2010
Changes in safety attitude and relationship to decreased postoperative morbidity and mortality following implementation of a checklist-based surgical safety intervention. February 9, 2011
Comparison of potential risk factors for medication errors with and without patient harm. August 18, 2010
6-PACK programme to decrease fall injuries in acute hospitals: cluster randomised controlled trial. June 22, 2016
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
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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
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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