Feedback incident reports

Feedback and error communication Feedback of incident reporting communication of specific patient safety issues (e.g. hemovigilance) mandatory education of new staff on patient safety discussion of feedback incident reports with units on regular basis in order to implement improvements patient safety column in hospital magazine patient safety dashboard via intranet designation of incident administrator... 

In addition to these types of evaluations, the incident reporting and near miss systems should be monitored for improvements in performance that can be attributed to the program. On the basis of feedback from these and other sources such as changes in quality levels or efficiency, modifications should be made to the program to enhance and sustain its effectiveness. Concrete evidence regarding the benefits arising from the program should be communicated to those involved. 

Company management takes the standards, regulations, and other general controls on its behavior and translates them into specific policy and standards for the company. Many companies have a general safety policy (it is required by law in Great Britain) as well as more detailed standards documents. Feedback may come in the form of status reports, risk assessments, and incident reports. 

The reporting system now provides a way for operators of each nuclear power plant to reflect on their own operating experience in order to identify problems, interpret the reasons for these problems, and select corrective actions to ameliorate the problems and their causes. Incident reviews serve as important vehicles for self-analysis, knowledge sharing across boundaries inside and outside specific plants, and development of problem-resolution efforts. Both INPO and the NRC issue various letters and reports to make the industry aware of incidents as part of operating experience feedback, as does IAEA s Incident Reporting System. 

The Confidential Human Factors Incident Reporting Programme (CHIRP) Administered by an independent body and which provides sensitive follow-up and feedback on reports of human errors that have been rendered anonymous. 

Reproduced from Quality Safety in Health Care, J Benn, M Koutantji, L Wallace et al. "Feedback from incident reporting information and action to improve patient safet/ . 18, no. 1. [11-21], 2009, with permission from BMJ Publishing Group Ltd. 

Along with incident reporting systems, hospitals should consider implementing After Event Reviews (AERs). InanAER, individuals discuss and provide feedback on critical events with the aim of detecting and learning from errors. Not ordy does this provide a forum to learn fiom errors, it also helps create a mindset that errors... 

Lack of feedback from the incident reporting system prevented oigaitisation-wide learning. 

We are given feedback about changes put into place based on the incident reports ... 

Berni, J., Koutantji, M., Wallace, L., Spurgeon, R, Rejman, M., Healey, A. and dncent, C. 2009. Feedback from incident reporting Information and action to improve patient safety. Quality and Safety in Healthcare, 18,11-20. 

Apply the same technique to safety. Let employees and Une management buy into the system. To do this, one must make safety exciting, a challenge. Competitive goals must be set and monitored on a regular basis. Ongoing feedback and updates on near miss incidents reported keep employees informed and involved and spurs them on to continue observing for hazards. 

For the system to be credible and acceptable to employees at all levels, it must have the support of the leadership of the organization. There should be a commitment from the executives to participate in the system and to maintain it as an ongoing process rather than just a flavor of the month safety gimmick. Feedback to near miss incident reporters and the workforce and follow up action on hazards reported is essential to give the system credibility. 

What is important is the feedback and action instigated by management to rectify the hazard if the event reported wasn t already closed out at the time of the report. For example, an employee notices some 2 x 4s with protruding nails laying in the walkway. He removes the nails and places the wood in a proper storage area. He then fills in the near miss incident report form as follows ... 

Feedback derived from incident reports keeps system actors in the loop and encourages agent participation in safety improvement. Operators can see that their concerns are being followed up effectively. 

FIG. 71. Objective tree for Levels 1-4 of defence in depth (IRS, Incident Reporting System WANO, World Association of Nuclear Operators INFO, Institute of Nuclear Power Operations). Safety principle (299) feedback of operating experience. 

An effective incident reporting and evaluation system should support privacy and receive information from a broad range of individuals. Reporting systems should also provide timely feedback and contain mechanisms that ensure evaluation and corrective action plan creation. The reporting process should promote a continuous flow of information into the system. Use reported information to assess and develop appropriate educational or training sessions. 

The standards specify feedback mechanisms for the handling of incidents and deviations, including requirements on incident reporting, inspections, and follow-up action. 

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