Reporting in Healthcare
BY:
DR SHIMA MOHAMED NAGUIB
(MQM- TQM- DHHM)
Objectives of Reporting
• Ensure transparency
• Support decision-making
• Monitor performance
• Improve patient safety
• Comply with regulations
Types of Reports in Healthcare
• Incident Reports
• Daily/Monthly Performance Reports
• Patient Safety Reports
• Audit and Compliance Reports
• Infection Control Reports
Roles and Responsibilities in Reporting
• Healthcare Staff: Incident reporting
• Quality Officer: Data analysis and report generation
• Unit Head: Review and action planning
• Admin: Archiving and compliance tracking
Why doctors may not report
• Feelings of shame or guilt
• Fear of punishment/ retribution
• Membership of profession that values perfection
• System factors
• Inadequate or no feedback
• Time constraints
• Lack of confidentiality
• Failure to respect or have faith in process
• Lack of knowledge on how to report
˚
Challenges in Reporting
• Incomplete data
• Lack of feedback
• Time constraints
• Staff training gaps
Outcome Definitions
• Incident: An event or circumstance which
could have or did harm a patient
• Adverse event: An incident that harmed a
patient
• Incidents = Near misses (90%) + Adverse
events (10%)
Be Smart
• Errors are inevitable
• When errors happen in the clinical environment the
consequences can be devastating
• Always consider circumstances when errors might occur
and think of ways to minimise the errors and their effects…
What is an Incident?
• Any unintended event that could have or did result in
harm to a patient, visitor, or staff. Includes:
• Medication errors
• Patient falls
• Equipment failure
• Documentation errors
Types of Incidents
• Clinical Incidents (e.g., wrong medication)
• Safety Incidents (e.g., patient fall)
• Environmental Incidents (e.g., power failure)
• Behavioral Incidents (e.g., aggression)
Objectives of Incident Reporting
• Identify risks and prevent recurrence
• Improve patient safety
• Promote accountability
• Enable data-driven improvements
• Comply with legal requirements
Incident Reporting Workflow
1. Identify and manage the incident immediately
2. Complete incident report form
3. Submit to quality/safety officer
4. Review and investigation
5. Corrective action and follow-up
Sample Incident Report - Data Example
• Date: 12 June 2025
• Location: Room 102
• Type: Medication Error
• Description: Wrong dose administered
• Immediate Action: Patient monitored, doctor notified
• Follow-Up: Staff re-educated, protocol revised
Roles and Responsibilities
• Staff: Report the incident immediately
• Supervisor: Ensure report completion
• Quality Officer: Investigate and follow-up
• Management: Take corrective action and document
learning
Tools Used in Incident Reporting
• Manual OVR forms
• Electronic Incident Management Systems
• Root Cause Analysis templates
• Audit and tracking sheets
Analysis and Action
• Use trend analysis to identify recurring issues
• Prioritize high-risk incidents
• Develop action plans
• Track implementation and outcomes
Learning and Prevention
• Share lessons learned with all staff
• Conduct regular training
• Update protocols and policies
• Promote safety culture
Adverse events happen
• Think about an incident you were involved in
• What happened?
• What was the error?
• What happened next?
Think more about the facts, not how it felt. We will be
dealing with the feelings and emotions later in the
session
What should happen
after an adverse event?
• Assessment & treatment of
patient to minimise harm
• Open disclosure
• Identification & notification of
the adverse event
• Review of circumstances &
contributing factors
Open disclosure =
open communication
Open Disclosure refers to open
communication when things go
wrong in health care and include:
1. An expression of regret;
2. A factual explanation of
what happened;
3. Consequences of the
event; and
4. Steps being taken to
manage the event and
prevent a recurrence.
Feelings/reactions
In response to their mistakes
doctors said the support they
needed was
•63% someone to talk to
•59% reaffirmation of their
professional competency
•48% validation in their decision
making process
•30% reassurance of self worth
The emotional impact of mistakes on family physicians.
Newman MC 1996
Where to go for support
1- Registrar/Consultant
2- Medical Staff Officer
3- Director of Clinical Training
4- Medico Legal Advisor
Any questions?
Summary and Recommendations
• Report all incidents without fear
• Act quickly and document accurately
• Use data for improvement
• Engage all staff in the process
Thank You
