Characteristics of Successful Incident Reporting Systems

As indicated in Table 83-15 , the establishment of an effective incident reporting and analysis system is important for any HRO. Health care is only now starting to develop such systems, due largely to the prevailing culture of blame and medicolegal risk. The details of successful incident reporting are beyond the scope of this chapter

TABLE 83-15 -- Prerequisites for an effective incident reporting system

• Both near-misses and actual accidents can be reported

• Reporting is simple but provides adequate information

• Personnel are provided with incentives for reporting

• The system is non-punitive for the reporting individual or institution

• Confidential or anonymous reporting

• Use immunity

• Transactional immunity

• The reporting system is independent of regulatory authorities

• Reports are analyzed by experts; analysis is oriented to systems and human factors

• Warnings and system changes follow from the analyzed reports

but are covered in a number of publications.^{[7] [59] [307] [308] [309] [310] [311] [312] [313] [314] [315] [316] [317] [318] [319] [320]} A model in the medical domain is the Patient Safety Reporting System of the Veterans Health Administration in the United States (http://www.psrs.arc.nasa.gov/).