From paper tigers to consumer-centered quality assurance tools: reforming incident-reporting systems

A practical framework for program administrators seeking to improve the effectiveness of their incident reporting and investigation procedures and practices was provided. Too often, these systems, which are designed by outside parties, are viewed by program administrators as instruments of risk exposure rather than viable tools for risk management and quality improvement. Program administrators were encouraged to take control of their incident-reporting systems by transforming them into viable consumer-centered quality assurance tools to meet the quality improvement needs of their own program. Specific performance indicators for effective systems were proposed, including consumer-centeredness; accountable reporting; thorough fact-finding; and prompt identification and implementation of corrective actions, fairness, and cost-effectiveness.