Table 4 Specialist books and technical reports for data synthesis and analysis
Entry | Authors | Title | Type | Content (gist) |
|---|---|---|---|---|
37 | Aktionsbündnis Patientensicherheit (2007) [56] | Empfehlungen zur Einführung von Critical Incident Reporting Systemen (CIRS) | Recommendations for action | In fact, a well-implemented CIRS is seen as an effective way to minimize risk. CIRS data in clinical risk management may prevent high consequential costs and promote safety and culture. |
38 | Gluyas/Morrison (2013) [11] | Patient Safety – An Essential Guide | Specialist book | The sole collection of CI reports did not improve patient safety automatically. To do so, the underlying factors of a certain incident must be identified and analysed. In addition, both reports and data must be evaluated with respect to probable trends or developments. |
39 | Gunkel et al. (2013) [9] | CIRS – Gemeinsames Lernen durch Berichts- und Lernsysteme | Technical contribution | CIRS indices are often skewed and ambiguous. More reliable parameters are the number of CI reports (per month or organizational unit), number of reports including analyses, number of implemented improvement measures. |
40 | Hofinger et al. (2008) [57] | Das Lernen aus Zwischenfällen lernen: Incident Reporting im Krankenhaus | Specialist book | Implementation and establishment of reporting systems in hospitals requires stamina and top management commitment. Privileges are detrimental to an effective establishment. Confidence-building measures are mandatory. |
41 | Kaloud (2009) [37] | Das Fehlermelde- und Präventionssystem “CIRPS” | Technical contribution | The practical implementation of CIRPS (‘Critical Incident Reporting and Prevention System’) of the “Allgemeine Unfallversicherungsanstalt” (AUVA) (Austria) started in 2006. Between October 2006 and October 2008, 294 changes were made as a result of 113 CIRPS reports. |
42 | Schreiner-Hecheltjen (2015) [51] | Qualitätsmanagement und Qualitätssicherung in der Medizin | Specialist book | CIRS is adapted for identification of CI in daily routine work and under conditions of certification. In addition, CIRS serves as an effective communication tool. Efforts are undertaken to connect CIRS networks of different hospitals. |
43 | Klauber et al. (Eds.) (2014) [41] | Krankenhausreport 2014: Schwerpunkt Patientensicherheit | Specialist book | Voluntary reporting systems are regarded as tools for identifying weak spots in hospitals. A survey from 2010 cited therein revealed that 35% of 484 acute care hospitals with more than 50 hospital beds employed locale report and learning systems over 2 years on average. |
44 | Koebberling (2005) [58] | Das Critical Incident Reporting System (CIRS) als Mittel zur Qualitätsverbesserung in der Medizin | Technical contribution | The concept of CIRS is founded on the observation that there is a correlation between the occurrence of incidents or near misses without consequences and severe incidents with consequences. Transparency and veracity is deemed as prerequisite for a well-functioning error management. |
45 | Koebberling (2008) [47] | Lernen aus CIRS – eine Kasuistik | Technical contribution | A good collaborative work between CIRS teams and QM teams is decisive for a well-functioning CIRS. The implementation of CIRS denotes a contribution to clinical risk management. |
46 | Levinson (2012) [59] | Hospital Incident Reporting Systems Do Not Capture Most Patient Harm | Technical contribution | As a matter of fact, 86% of occurred incidents are not reported. This is attributed to misjudgement and lack of perception. As a consequence, clear reporting policies and staff training are recommended. |
47 | Mahajan (2010) [44] | Critical Incident Reporting and Learning | Technical contribution | CI reporting is deemed as a key in improving safety but underutilized in health care. A non-punitive handling of reports as well as regular and detailed feedback is crucial in engaging clinical staff in the safety loop. Immediate incidents such as falls or equipment errors are better reported than subtle incidents with gradual development. |
48 | Merkle (2014) [29] | Risikomanagement und Fehlervermeidung im Krankenhaus | Specialist book | Incident-reporting systems are successful when they are a component part of clinical risk management and a process management focusing on patients is implemented. |
49 | PHAM, GIRARD, Pronovost (2013) [49] | What do with healthcare incident reporting systems? | Technical contribution | Despite its influence on improving patient safety, several limitations of CIRS have been addressed. Significant values of CIRS and strategies to maximize value were also taken into account. |
50 | Rohe et al. (2014) [60] | Erfahrungen mit Critical Incident Reporting-Systemen | Technical contribution | The Ärztliche Zentrum für Qualität in der Medizin (ÄZQ) recommends that only near misses without consequences are worth to be reported. Reports on consequences should be included when the liability and insurance are clarified beforehand. |
51 | Rohe/Thomeczek (2008) [61] | Aus Fehlern lernen: Risikomanagement mit Fehlerberichtssystemen | Technical contribution | Safety culture and patient safety might be strengthened by relevant analyses, reasonable improvement strategies, and consistent reporting systems with relevant key figures. However, the causal relationship between introducing a reporting system and changes of the number of incident occurrences can never be clarified. |
52 | Rose/Hess (2008) [36] | Melden von Near Misses im Krankenhaus | Technical contribution | It is estimated that about 50% of incidents with potential harm to patients could be avoided. In a specific hospital reposting system that resembles to CIRS, it was possible to promote active handling of safety issues, resulting in a positive effect on the management of failures and damages. The reporting system is deemed as a first step in the development of clinical risk management. |
53 | St. Pierre (2013) [32] | Safe patient care- safety culture and risk management in otorhinolaryngology | Technical contribution | CIRS is useless in the absence of clinical risk management and QM systems. Furthermore, both technical and non-technical skills of health care professionals are deemed as decisive with respect to a safe and efficient delivery of patient care. |
54 | Waterson (2014) [62] | Patient safety culture: theory, methods and application | Specialist book | The number of CI reports can be explained by two ways. First, it can mean a high-risk potential and a high probability of a patient harm. Second, it can be seen as an indicator of an organizational culture of openness and willingness to learn. |
55 | Weimann/Weimann (2013) [28] | Das Swiss Cheese Model als “critical incident reporting system” zur Risikoreduzierung und Erhöhung der Patientensicherheit in Klinik und Praxis | Technical contribution | CIRS serves as an example of a “Swiss Cheese Model”. All staff members have to know how to deal with CIRS, pointing to the necessity of transparency because in hospitals, error analysis is often associated with recrimination. |
56 | Zapp (Eds.) (2011) [63] | Risikomanagement in Stationären Gesundheitsunternehmungen. Grundlagen, Relevanz und Anwendungsbeispiele aus der Praxis | Specialist book | In comparison to a control group, the implementation of CIRS give rise to changes in communication and collaboration, in the attitude toward error management, accountability, and assessment of safety measures. |