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Incident Reporting at a Tertiary Care Hospital in Saudi Arabia

Yaseen Arabi, MD, FCCP, FCCM,*Þþ Ahmed Alamry, MD, MHA, FRCPC,§||¶ Souzan M. Al Owais, RPh, CPHQ,|| Hasan Al-Dorzi, MD,* Seema Noushad, MBBS,*

and Saadi Taher, MD, FRCP**

Objective: This study aimed to examine the rates and categories of incident reports in an academic tertiary care center in Saudi Arabia both hospital-wide and in the intensive care unit (ICU). Such information would help in redesigning systems and in planning and developing strategies with the goal of improving patient safety and quality of care. Methods: In this descriptive study, we evaluated all incident reports submitted through the paper-based reporting system in the hospital and the ICU for the year 2008. Incident report rates were calculated as the number of incident reports per 1000 patient days. We also reviewed the major and minor categories of the generated reports. Results: A total of 3041 incident reports were submitted from all hospital areas; yielding a rate of 5.8 per 1000 patient days. Sixty-two incident reports were reported from the ICU, yielding a rate of 5.8 per 1000 patient days. The most frequent type of incident reports was pro- cedural variances (37%), followed by behavior and communication in- cidents (34%), hazardous and safety incidents (9.5%), and medication errors (7.4%). In the ICU, the most frequently reported type of incidents was behavior and communication incidents (30.6%), followed by proce- dural variances (21%) and medication errors (13%). Conclusions: Rates of incident reports at a tertiary care center in Saudi Arabia were low compared with reported international rates. The main categories of incident reports were related to procedural variances and behavior and communication incidents. These findings suggest that patient safety initiatives should focus primarily on these 2 domains. Additional prospective research is needed in this important area to further understand patient safety challenges and reporting practice and culture in the country.

Key Words: intensive care units, safety culture, quality control, critical care, administration, quality assurance, health care, culture, Saudi Arabia, incident report, medical errors, voluntary programs, systems analysis, hospital information systems

(J Patient Saf 2012;8: 00Y00)

Incident reporting has been used as a tool in patient safetyinitiatives to identify errors, high-risk situations, mistakes, and violations,1 with the goal of learning from them to prevent their

recurrence.2 This is particularly relevant in high-risk areas such as the intensive care unit (ICU)3 where the incidence of errors and resulting adverse events has been reported to be as high as 2 errors per patient per day; and where 1 in 5 ICU patients sustain a serious adverse event that has a significant risk for harm.2 Incident reporting varies considerably based on a com- plex interaction of factors especially the reporting culture. Data on incident reporting from North America,4,5 United Kingdom,6

Australia,7,8 Japan,9 and other countries exist.10 However, there are limited data on this important topic from Saudi Arabia, where health care quality and medical errors has become the center of attention in response to increased awareness of medical errors worldwide, media coverage, and public pressure.

The health care system in Saudi Arabia has its unique features that are likely to affect patient safety and reporting culture, including its rapid growth and the multinational het- erogeneous nature of its staffing with their different cultural and training backgrounds. As such, we sought to study incident reporting in an academic tertiary care center in Saudi Arabia by examining the rates and categories of incident reports in the hospital in general and in the ICU in particular. Such informa- tion would help in redesigning systems and in planning and developing strategies with the goal of improving patient safety and quality of care.

METHODS

Study Setting This is a descriptive study of the paper-based incident re-

ports that were registered at King Abdulaziz Medical City (KAMC) - Riyadh, between January 1 and December 31, 2008. KAMC is a 900-bed university-affiliated tertiary care center in Riyadh, Saudi Arabia, is accredited by the Joint Commission International and is staffed by more than 10,000 employees from more than 52 nationalities. It also has residency programs for different specialties. The primary language used for medical and nursing care is English, although Arabic is the language used to communicate with patients and families. The ICU at KAMC is a 21-bed closed medical and surgical unit and is staffed by on- site board-certified intensivists on a 24/7 basis. Residents and fellows from different specialties rotate in the ICU as part of their training requirements. Nursing staff-to-patient ratio is 1:1. Clinical rounds are multidisciplinary and include physicians, critical care nurses, clinical pharmacists, and respiratory thera- pists. The Quality Management Department reports to Medical Services and oversees all patient safety initiatives and quality programs at the hospital.

Definition and Process of Incident Reporting at KAMC

Incident reporting is defined in our hospital as the process of voluntary reporting of any event, accident or deviation from policies, that is not consistent with the routine operation of the

ORIGINAL ARTICLE

J Patient Saf & Volume 8, Number 2, June 2012 www.journalpatientsafety.com 1

Copyeditor: Jam Polintan

From theAQ1 *Intensive Care Unit, Intensive Care Department and †Respiratory Services, King Abdulaziz Medical City; ‡King Saud Bin Abdulaziz Uni- versity; §Health System and Quality Management, King Saud Bin Abdulaziz University for Health Sciences; and ||Quality Management Department, National Guard Health Affairs, ¶Department of Emergency Medicine, and **Medical Services, National Guard Health Affairs, King Abdulaziz Medical City, Riyadh, Saudi Arabia. Correspondence: Yaseen Arabi, MD, FCCP, FCCM, Intensive Care

Unit 1425, King Abdulaziz Medical City, Riyadh, Saudi Arabia (e-mail: [email protected]).

The authors disclose no conflict of interest. The authors did not receive funding for this study. Supplemental digital contents are available for this article. Direct URL

citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.journalpatientsafety.com).

TABLE 1. Major and Minor Categories Classification of Incident Reports

Major Category Definition Examples of Minor Categories

Medication errors Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient, or consumer

& Drug discontinued without order & Drug mislabeled & Drug omitted & Drug outdated & Drug out of stock & Intravenous pump problem & Medication administration record error & Order processing/verification error & Pharmacy related error & Preventable adverse drug reaction & Wrong dose/rate & Wrong drug & Wrong patient & Wrong route & Wrong time

Behavior and communication incidents

Incident related to patient, family, or staff behaviors or incident related to the exchange of information among employees

& Inappropriate patient behavior & Inappropriate family behavior & Inappropriate staff behavior or communication & Patient discharge against medical advise & Patient absconding & Patient or family dissatisfied with care & Borrowed medical record card by other patient

Intravenous complications Complications arising from establishing of an intravenous. access or infusion of intravenous drug

& Extravasation of medication/fluid & Central line related complication & Contrast media reaction & Insertion site red/swollen & Occluded intravenous access

Procedural variances Any incident related to deviation from the organizational policies and procedures or standards of practice

& Admit-no bed* & Cancelled or delay in procedures or services & Charting error & Consent form not completed & Interventions initiated without verbal or telephone orders

& Laboratory specimen lost or spoiled & Laboratory specimen contamination & Missing medical records & No response of service & No available service or provider & Patient misidentification incidents & Wrong patient & Wrong procedure followed or performed

Security variances Any incident related to a breach of security that has taken place within the hospital premises

& Damage or loss of hospital property & Narcotic drug count variance & Narcotic drug keys lost & Suicide attempt & Unauthorized smoking

Needles and sharps injuries Any skin cut wound, typically set by a needle point, or also by other sharp instruments or objects

& Improper sharps disposal & Injury related to an instrument other than needles

& Injury related to recapping incident

Arabi et al J Patient Saf & Volume 8, Number 2, June 2012

2 www.journalpatientsafety.com * 2012 Lippincott Williams & Wilkins

medical center and that potentially may, or actually did, result in harm injury or loss to any patient, staff, student, or visitor on the premises of the health care facility. Similar to other inter- nationally existing systems,11 the reported event or incident may or may not have been preventable and may or may not have in- volved an error from the health care team.

In 2008, the incident reporting system at KAMC-Riyadh was a paper-based tool called the ‘‘Occurrence/Variance/ Accident’’ (OVA) report (see Figure, Supplemental Digital Content). All staff members were encouraged to report within 24 hours any event, accident, or deviation from policies or pro- cedures involving a patient, staff, or others who were on the premise of the hospital. Reporting was voluntary, nonanonymous, yet confidential. Information about the patient affected and/or staff involved in the event was not subject to disclosure to other than a few people who were involved in the process of incident investigation. The staff member filled an incident report form that contained tick boxes to classify the incident into major and minor incident categories as described inT1 Table 1 in addition to a handwritten narrative to describe the nature of the event.

These categories included medication errors, intravenous com- plications, security variances, behavior and communication in- cidents, needles and sharps injuries, falls incidents, procedural variances, equipment incidents and hazards, and safety incidents. The staff member was required to document the following in- formation: details of the person involved in the incident (if applicable)Vpatient, staff, or visitor; the location where the in- cident had occurred, including the specialty under which the patient was admitted; the date and time of the incident; and the name, title, and the unit of the reporter.

The form was then forwarded to the unit’s manager/ supervisor for review. The original report was kept at the orig- inating unit and the other 2-carbonless copies were sent to the relevant units or departments for responses and necessary re- solutions. The concerned units or departments reviewed the re- ceived report, completed a full investigation, and documented the contributing factors and action plan in the allocated field on the incident report form to address the deficits and mitigate the harm (if any). The form was then sent back to the originat- ing unit for review and evaluation of the action plan. The unit

TABLE 1. (Continued)

Major Category Definition Examples of Minor Categories

Hazardous and safety incidents Incidents related to chemical, physical, or other hazardous agents, which, if released or misused, can pose a threat to the environment or health of staff and patients

& Chemical spill/splash & Electrical shock & Fire & Gas leak & Improper disposal of hazardous waste & Injury due to inappropriate body mechanics & Radiation exposure & Water spill & Work related burns & Work-related infection

Falls incidents Fall is defined as a sudden, uncontrolled, unintentional, downward displacement of the body to the ground or other object, excluding falls from violent blows or other purposeful actions

Blood and blood products incidents

Adverse events related to preparation, delivery, or use of blood and blood products

& Adverse reaction to blood transfusion & Expired product & Wrong packed red blood cells & Wrong plasma & Wrong platelets

Equipments incidents Any incident regarding unavailability or malfunction of any piece of organizational equipment. Examples of equipments are categorized under the following minor categories:

& Bed & Cardiac monitor & Computer support & Dialyzers & Electrocautery & Electronic thermometer & Glucometer & Intravenous pump & Out-of-stock equipment & Pager & Pulse/oximeter & Stretcher & Wheelchair & X-ray machine

*Patients who are boarded in the emergency care center after the decision to admit the patient is taken but have not been transferred to an inpatient unit owing to unavailability of beds.

J Patient Saf & Volume 8, Number 2, June 2012 Incident Reporting in Saudi Arabia AQ2

* 2012 Lippincott Williams & Wilkins www.journalpatientsafety.com 3

manager/supervisor signed the form and sent the original and the carbonless copies to the Risk Management Unit in Quality Management. The Risk Management staff provided a final re- view to ensure completeness and appropriateness of the classi- fication (selection of the incidents’ major and minor categories) according to the nature of the incident and then assigned the incident’s severity level. The classification of the event into the relative major and minor categories relied mostly on the initial classifications made by the reporter. Incomplete reports that were not properly addressed were sent back to the concerned unit for follow-up. Finally, the incident report was marked as ‘‘closed’’; information was entered into an access database by a data-entry clerk. Serious untoward clinical incidents (unex- pected death or serious outcomes) were escalated to the director of Quality Management Department and investigated via a dif- ferent mechanism, where a team was formulated to perform a root cause analysis. On a quarterly basis, the database was in- terrogated and a summary report of the data was generated to identify the rates and major categories of incidents reported from each clinical department. The report was then sent to the higher management, concerned units, departments, and committees.

Study Design In this descriptive study, we evaluated submitted incident

reports from all hospital areas including the ICU for the year 2008 (from January 1 to December 31) and calculated incident report rates as number of incident reports per 1000 patient days. We also reviewed the classifications (major categories) of the generated incident reports and further analyzed the top 2 re- ported major categories into their respective minor categories. Each report was counted separately even if more than 1 report affected the same patient or individual.

RESULTS

Rates of Incident Reports During the study period, there were 38,171 hospital

admissions accounting for 252,851 patient days. There were a total of 3041 incident reports from all hospital areas, of which 1464 occurred in the inpatient setting, the rest were from out- patient and nonclinical areas. As such, incidents were reported at a rate of 5.8 per 1000 patient days. During the same pe- riod, there were 1184 admissions to the ICU accounting for 10,630 patient days. Sixty-two incidents were reported from the ICU, accounting for 2% of the total hospital incidents and yielding a rate of 5.8 per 1000 patient days.

Major Categories of Incident Reports The most common major categories of incident reports

( T2Table 2) were procedural variances (37%) followed by behavior and communication incidents (34%) and hazardous and safety incidents (10%). In the ICU, the most common major categories (Table 2) were behavior and communication incidents (31%), followed by procedural variances (21%), hazardous and safety incidents (13%), medication errors (13%), needles and sharps injuries (8%), equipment incidents (7%), and intravenous com- plications (6%). There were no reported incidents related to falls or security variances in the ICU.

Minor Categories of Incident Reports Related to Procedural Variances

Of the 1119 procedural variances reports, the most com- mon minor categories ( T3Table 3) were related to admit-no bed (51%), followed by wrong procedures (9%), and cancellation or delay in procedures or services (8.4%). In the ICU, 54% of incident reports related to procedural variances were classified as ‘‘none specified’’ category (Table 3) because of insufficient descriptions to determine the minor incident category. This was followed by patient identification incidents (23%) and cancel- lation or delay in procedures or services (15%).

Minor Categories of Incident Reports Related to Behavior and Communication Incidents

Of the 1043 behavior and communication incidents, the most common minor categories ( T4Table 4) were related to patient discharge against medical advice and patient absconding (55%), inappropriate family behavior (7%), and inappropriate staff behavior or communication (5%). In the ICU, the most com- mon minor category of the behavior and communication inci- dents (Table 4) was related to inappropriate staff behavior or communication (47%), followed by inappropriate family be- havior (15.8%).

DISCUSSION Our study shows that in a tertiary care hospital in Saudi

Arabia, incident reports occurred at a rate of 5.8 per 1000 patient days. In the ICU, incident report rate was similarly 5.8 per 1000 patient days. The main categories of incident reports were re- lated to procedural variances followed by behavior and commu- nication incidents accounting for more than 70% of all reported incidents.

There is a considerable variation in the reported rates of incidents in the literature. In a study of 26 acute care hospitals in

TABLE 2. Major Categories of Incident Reports in the Hospital and in ICU

Variable Hospital (n = 3041)

ICU (n = 62)

Procedural variances, n (%) 1119 (36.8) 13 (21) Behavior and communication incidents, n (%)

1043 (34.3) 19 (30.6)

Hazardous and safety incidents, n (%) 289 (9.5) 8 (12.9) Medication errors, n (%) 226 (7.4) 8 (13) Intravenous complications, n (%) 111 (3.7) 4 (6.5) Equipment incidents, n (%) 74 (2.4) 5 (6.8) Falls incidents, n (%) 78 (2.6) 0 (0) Security variances, n (%) 54 (1.8) 0 (0) Needles and sharps injuries, n (%) 47 (1.5) 5 (8.1)

TABLE 3. Minor Categories of Behavior and Communication Incidents in the Hospital and in ICU

Variable Hospital (n = 1043)

ICU (n = 19)

Patient discharge against medical advice and patient absconding, n (%)

578 (55.4) 2 (10.5)

Inappropriate family behavior, n (%) 70 (6.7) 3 (15.8) Inappropriate staff behavior or communication, n (%)

50 (4.8) 9 (47.4)

Inappropriate patient behavior, n (%) 41 (3.9) 1 (5.3) Patient or family dissatisfied with care, n (%) 13 (1.2) 0 (0) Borrowed medical record card by other patient, n (%)

4 (0.4) 0 (0)

Arabi et al J Patient Saf & Volume 8, Number 2, June 2012

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the United States using an electronic reporting system, reporting rates varied considerably from 9 to 95 reports per 1000 patient days.12 In a multicenter Australian study, the reporting rate was 4 to 6 reports per 1000 patient days.13 In a study from 418 hospi- tals in Japan, the mean rate of incident reports by physicians was 0.26 and by nurses 9.13 per 1000 patient days.14 There are several factors that could explain such variability, including differences in patient population, reporting methodology, and definition of incident categories but, more importantly, report- ing culture.15 It has been shown that, even in settings with high rate of voluntary reporting, the actual rate of incidents is signif- icantly higher. When medical errors were studied prospectively in a critical care setting using a multifaceted approach including direct continuous observation, the rates per 1000 patient days for all adverse events, preventable adverse events, and serious errors were 80.5, 36.2, and 149.7, respectively.16

When compared with internationally reported rates, our re- porting rates fell in the low range probably representing under- reporting of incidents. In a recent study of 13 general hospitals in Saudi Arabia with voluntary reporting systems, 43% of health care professionals did not report any incident in a year and 30% reported fewer than 2 events.17 There are several rea- sons for underreporting. First, underreporting is a common fea- ture to voluntary reporting systems as other international studies have shown that up to 96% of medical errors and adverse events are not reported.18 Second, underreporting may be related to reporting culture in the organization and the society. Studies have shown that organizational and professional culture do influence the reporting behavior of individuals,19,20 and certainly, this was the experience of the authors in our organization, although this needs to be studied further. The influence of the social culture and norms may explain, at least in part, the variations observed among studies from United States, Japan, and Saudi Arabia. The presumed underreporting of incidents in our institution was an impetus to conduct a comprehensive patient safety culture sur- vey in 2010, the results of which are being analyzed to better understand the patient safety culture in our organization. Third, underreporting in our study might have been related to the fact that incident reporting is nonanonymous. Reporting systems vary

in relation to anonymity of reporters; some systems require identification of the reporters (no anonymous), some permit voluntary identification, and others are anonymous. The lack of reporter anonymity is likely to decrease the rates of incident re- porting and AQ3detection21 and increases the psychological resis- tance to reporting.22 Our organization opted to keep the incident reporting as nonanonymous for multiple reasons. These include the ability to ask the reporter for further details of a certain inci- dent, maintaining accountability, preventing prejudiced report- ing, and generating individual feedback to the person completing the form, all of which were clear advantages for adapting this strategy of reporting. Finally, underreporting may be also related to the process/tool of reporting and feedback mechanism.23

Several techniques have been used to enhance reporting. Elec- tronic incident information management systems have been used to facilitate incident reporting.7,22,24Y26 However, some studies showed higher reporting with paper-based systems.27,28 Other authors augmented reporting by ‘‘facilitation’’ having a senior ICU clinician encouraging all staff to identify incidents and by discussing incident monitoring at bedside rounds, consultations, or grand round presentations.29

Despite these limitations, data on incident reporting have been used widely as a source of information about errors and safety concerns. Analysis of clinical incidents has been used as a window on the system, helping the hospital and units’ lead- ership in prioritizing decisions and strategies. However, only limited data are available on the impact of voluntary incident reporting systems on patient safety.30

Our study demonstrates that the leading categories of inci- dents reported in a tertiary care hospital were related to proce- dural variances and behavior and communication incidents. This is in line with other studies that highlighted the importance of human factors in contributing to incidents.31

We found that the leading category of incident reports was procedural variances, signifying deviation from the orga- nizational policies and procedures. In 1 study,32 failure to follow established protocols contributed to 32% of 2075 incidents reported at 23 adult and pediatric ICUs in the United States. We believe that enhancing awareness, knowledge, and compliance with policies and procedures of the organization helps stan- dardizing the patient care process, thus improving patient safety. Admit-no bed incidents (51%) constituted most procedural variances in our institution. Such incidents were initiated when patients were boarded in the emergency department awaiting for beds in the inpatient units. The admit-no bed incidents were a challenge for our hospital as a result of the dramatic increase in the demand for the hospital health care services during the past years. This issue triggered the hospital leadership to hire a third-party professional company to conduct a systematic study of patients’ flow process from the emergency department to the inpatient units. In addition, several expansion projects have been undertaken to secure enough beds for admitted patients.

Communication is a fundamental instrument by which phy- sicians, staff, and patients relate to each other and is crucial for proper medical and nursing care. Ineffective communication is a major issue in health care and has been described as a major factor in 60% to 70% of serious incidents.33 The multinational staffing with different cultures, languages, and backgrounds in our setting contributes to communication problems especially with families. The study also shows that the top minor category related to behavior and communication incidents was related to patient discharge against medical advice and patient abscond- ing (55%). In 1 qualitative study34 performed to understand why patients discharge themselves against medical advice, poor com- munication between providers and patients and between providers

TABLE 4. Minor Categories of Incidents Related to Procedural Variances in the Hospital and in ICU

Variable Hospital (n = 1119)

ICU (n = 13)

Admit-no bed, n (%) 570 (50.9) 0 Wrong procedure followed or performed, n (%)

104 (9.3) 0

Cancelled or delay in procedures or services, n (%)

93 (8.4) 2 (15)

Patient identification incidents, n (%) 31 (2.8) 3 (23) Charting error, n (%) 27 (2.4) 0 (0) Laboratory specimen lost or spoiled, n (%) 15 (1.3) 0 (0) No response of service, n (%) 14 (1.3) 0 (0) No available service or provider, n (%) 13 (1.2) 0 (0) Missing medical records, n (%) 12 (1.1) 0 (0) Laboratory specimen contamination, n (%) 11 (1.0) 0 Interventions initiated without verbal or telephone orders, n (%)

9 (0.8) 1 (8)

Wrong patient, n (%) 9 (0.8) 0 (0) Consent form not completed, n (%) 6 (0.5) 0 (0) Other, n (%) 205 (18.4) 7 (54)

J Patient Saf & Volume 8, Number 2, June 2012 Incident Reporting in Saudi Arabia

* 2012 Lippincott Williams & Wilkins www.journalpatientsafety.com 5

themselves was found to be an important cause. In our organi- zation, the Social Services Department regularly analyzed all cases events of discharge against medical advice and patient absconding, and improvement initiatives have been undertaken, such as patient education on the consequences of such events. Regarding the categories of incident reports in the ICU, our study shows that the top minor category related to behavior and communication incidents in the ICU was related to inappropriate staff behavior or communication (47%). The ICU is a complex environment where a high level of coordination and commu- nication between health care providers is essential. To improve communication, several initiatives have been undertaken, includ- ing the use of structured tools such as the situation-background- assessment-recommendation technique, which has been shown to enhance the quality of information exchange.35 Also, in the ICU, we have started a medical simulation programVa tool that has been also shown to enhance crisis management, including communication and teamwork, to reduce incidents and improve human performance.34 In addition, the ICU department started a weekly ‘‘Patient Safety and Quality Forum’’ to discuss serious patient safety incidents, identify opportunities for improvement, and foster a blame-free environment. The forum is a multidisci- plinary meeting that includes, but is not limited to, physicians, nurses, pharmacists, respiratory therapists, and social workers.

Voluntary paper-based systems for incident reporting have several limitations. The design of incident reports that rely on tick boxes probably aided in the ease of the reporting process but likely at the expense of having a rich-narrative incident de- scription. ther limitations included double entries, incomplete data, misclassification, unidentified contributory factors, and unknown severity of adverse events, thus biasing the apparent trends of incidents. Moreover, incident report classification was primarily made by reporters based on their understanding of the major and minor categories specified in the incident report form.

This limitation had been also faced by other organizations when reporters had limited understanding of the definitions and classifications of those events.21 In addition, relatively large numbers of incident reports were classified as ‘‘other’’ under the minor category classifications. The lack of detailed information

on the type of incident or contributory factors means that im- portant information that may lead to patient safety improve- ments was sometimes missing. Electronic reporting systems have been shown to be capture more complete data about inci- dents.22,26 We have recently implemented an electronic incident information management system (Safety Reporting System) that elicits a branching algorithm for the classification of reports with a drop-down list of incident types, predisposing factors, and measures to prevent the reoccurrence of similar incidents. Another limitation of voluntary reporting might have been dif- ferential reporting of certain categories of incidents such as behavior and communication issues. Reflective of that was the collective experience of the authors that, at least in some occa- sions, reporting was used as a punitive tool among staff, to the degree that the noun ‘‘OVA’’ turned into a verb as in ‘‘I will ‘OVA’ you.’’ Such safety culture may explain some of the bias seen in our study toward reporting of behavior and communi- cation incidents, and such limitation can only be minimized by improving safety culture within the organization. In addition, training has been shown to be effective in focusing incidents to report system issues rather than individuals do.36 Examples of issues identified from the incident reports that contributed to improvement initiatives pursued in the hospital and in the ICU are summarized in T5Table 5.

Our study should be evaluated in light of its limitations and strengths. Limitations of this study stem mainly from limi- tations of the incident reporting system itself, which were men- tioned earlier. In addition, the data available from the system did not allow analysis of harm and contributing factors. In addi- tion, it is a monocenter study. One of the main limitations to the voluntary reporting is that it represents only a small propor- tion of the actual incidents. Therefore, these data are not a true reflection of the actual incident rates, and careful conclusions should be drawn about the actual trends over time. The main goal of incident reports monitoring is not to collect epidemiologic data per se but to extract data that represent one of several po- tential sources of information about patient safety. On the other hand, this study highlights several important issues re- lated to incident reporting in Saudi Arabia and suggests areas for improvements.

TABLE 5. Examples of Improvement Initiatives Pursued in the Hospital and in the ICU as a Result of the Data on Incident Reports

Issue Identified From Incident Reports Improvement Initiatives

Low rate of incident reporting & Patient safety culture survey & Weekly ‘‘Patient Safety and Quality Forum’’ to discuss serious patient safety incidents and foster a blame-free environment

& Implementing an electronic incident information management system (Safety Reporting System)

Admit-no bed incidents & Hiring a third-party professional company to conduct a systematic study of the patient’s flow process

& Several expansion projects to secure additional beds for admitted patients Patient discharge against medical advice and patient absconding

& Implementation of a multidisciplinary education program by Social Services about the consequences of discharged against medical advice

High prevalence of behavior and communication incidents

& Implementation of SBAR technique & Starting a medical simulation program & Patient Safety and Quality Forum

Lack of detailed information on the type of incident or contributory factors

Implementing an electronic incident information management system (Safety Reporting System) that uses a lesser narrative description of incidents and elicits a branching algorithm for the classification of reports

SBAR indicates situation-background-assessment-recommendation.

Arabi et al J Patient Saf & Volume 8, Number 2, June 2012

6 www.journalpatientsafety.com * 2012 Lippincott Williams & Wilkins

In conclusion, our study reveals a low rate of incident re- porting in a tertiary care center in Saudi Arabia compared with reported international rates. The main incident categories re- ported were related to procedural variances and behavior and communication incidents. These findings suggest that patient safety initiatives should focus primarily on these 2 domains. Incident reporting systems represent a key safety tool, and in- cident report data could improve safety and quality of health care in hospitals. Clearly, further research is needed in this im- portant area, preferably in a prospective design to better under- stand safety challenges and reporting culture in the country.

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J Patient Saf & Volume 8, Number 2, June 2012 Incident Reporting in Saudi Arabia

* 2012 Lippincott Williams & Wilkins www.journalpatientsafety.com 7

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