Creating a web-based incident analysis and communication system

Hospitals perform root cause analyses (RCA) and implement action plans for sentinel events (SE) to prevent similar adverse events. Dissemination of RCA action plans between hospitals has been limited by an absence of universal definitions of terms and classification frameworks, which have been recently proposed by the World Health Organization's International Classification for Patient Safety (ICPS). Tools do not exist, however, to assist hospitals in performing SE reviews aligned with the ICPS framework.

We developed an intranet-based decision support tool that aligns SE reviews with the ICPS framework, and captures SEs and action plans into a searchable database for aggregate reporting. Its structural elements include: 1) encrypted database on a secure server; 2) decision support resources that align SE analyses with the ICPS classification; 3) drop-down lists and help tools to standardize input; 4) standardized individual and aggregate SE reports that vary depending on recipients; 5) real-time access to Web-based RCA resources; 6) fishbone diagramming; and 7) query functions for database searches.

Entry of 15 SE reports into the database framework identified gaps in our previous reviews. Safety personnel and health system leadership have expressed positive assessments of the database and approved funding for evaluation of system-wide implementation.

Expansion of our database to all safety incidents beyond SEs provides a resource for communicating safety opportunities between hospitals. We demonstrate how the ICPS classifications can be migrated into a decision support tool that has potential for standardizing root cause analyses, disseminating action plans, and improving patient safety.