Patients safety incident reporting: the who, what, where, when and why?

The landscape of patient safety is changing nationally and internationally. Recently, the number of preventable deaths in the USA annually is estimated at between 200,000-400,000.Nationally and internationally under-reporting of patient safety incidents is an opportunity for improvement. In 2015, 58.6% of patient related claims received by the State Claims Agency (SCA) had no previous patient safety incident reported, despite the legal obligation to report adverse events to the SCA. A detailed, national survey of the acute hospitals identified that there is significant variation in the modes and patterns of incident reporting, including variation in the percentage of incidents reported to the SCA, who decides what is reported, how it is reported, the backlog of incidents not reported and the time delay before reporting. This knowledge confirms that currently, comparisons between hospitals of equal activity are inaccurate. Reduction in variation and increased standardisation of patient safety incident reporting is required.