What does voluntary reporting system of patient safety incidents tell?

Background In Finland more than 300 health care and social service organizations use the voluntary reporting system of patient safety incidents (HaiPro). More than one million reports have been made. Here are the results.

Methods Most of the incident reports are included in the material, 847 492 in all. The material was analyzed with IBM SPSS Statistics software, version 23.

Results The number of reports per year is increasing. One third dealt with near miss events. In most of the cases that included patients the harm caused to the patients was not worse than mild. Most reports dealt with medication or fluid therapy, accidents, or information flow. The patients had almost always been informed of the harm. Doctors had made only about 2 % of the reports, but their reports included more often serious incidents. The most common contributory factors included patients and information flow. Suggestions for improvements were submitted fairly infrequently.

Conclusions Doctors’ reporting activity was low. The reason may be that they pay less attention to processes, and more to medicine and master-apprentice type individual guidance. However, in most cases this does not lead to multi-professional learning in the organization. Many approaches are needed to increase patient safety,
one essential approach being voluntary reporting of incidents, and correcting defective practices.