A qualitative analysis of critical incident reporting in a paediatric hospital: benefits and weaknesses

Area of Science:

• Pediatric Healthcare
• Patient Safety
• Quality Improvement

Background:

• Critical incident reporting systems (CIRSs) are valuable tools for enhancing healthcare safety.
• Data on CIRSs in pediatric facilities remain limited, necessitating further evaluation.
• This study assesses a CIRS within a pediatric hospital setting.

Purpose of the Study:

• To evaluate the benefits, weaknesses, and opportunities of a critical incident reporting system (CIRS) in a pediatric hospital.
• To analyze the types of incidents reported and their impact on patient care and hospital operations.
• To identify areas for improvement in the CIRS process and feedback mechanisms.

Main Methods:

• A qualitative analysis of all incidents reported in 2018 via an anonymous reporting tool (CIRS) at a children's hospital.
• Iterative categorization of incidents to group and analyze reported events.
• Focus on incident-related problems, error types, and potential avoidance strategies.

Main Results:

• 496 incidents were reported in 2018, with 307 directly impacting patients, 82 causing organizational issues, and 107 having no apparent problem.
• In most cases (398/496), the responsible caregiver was not informed; personal feedback was documented in only 46 instances.
• Fifty-two incidents were self-reported, indicating a reliance on the anonymous nature of the system.

Conclusions:

• The CIRS proved indispensable for identifying system-based errors, highlighting its value in pediatric settings.
• Many reported errors had individual, organizational, or no consequences, with a preference for anonymous reporting over direct feedback.
• While essential for system error detection, the CIRS requires mandatory personal feedback and potentially new tools to ensure learning and overcome communication barriers.