[From incident-reporting to morbidity and mortality rounds]

Area of Science:

• Healthcare Management
• Patient Safety
• Clinical Informatics

Background:

• Hospitals increasingly adopt digital systems for operational efficiency and safety.
• Effective incident reporting is crucial for identifying and mitigating patient harm.
• Sustaining staff engagement in reporting systems presents a persistent challenge.

Purpose of the Study:

• To evaluate the effectiveness of a computer-based incident reporting system.
• To assess staff engagement and the analysis process of reported incidents.
• To identify challenges in implementing improvements from incident reports.

Main Methods:

• Implementation of a hospital-wide computer-based incident reporting system in 2015.
• Ongoing analysis of all reported incidents.
• Selection of high-impact incidents for presentation at morbidity and mortality (M&M) conferences and publication as clinical cases.

Main Results:

• Consistent staff interest in the reporting system, with approximately two reports per day.
• Systematic analysis of incidents, with a focus on impact and improvement potential.
• Regular dissemination of findings through M&M conferences and clinical case publications.

Conclusions:

• The implemented system has fostered a culture of reporting and continuous improvement.
• Translating analyzed incidents into daily practice and managing complex cases requires further resources.
• Sustained success hinges on resource allocation and integrating reported improvements into routine care.