LR5 / Reporting and learning systems involving patients

Type of Patient Safety Practice
Clinical Practice (CP)
Related practices from PaSQ database
“Best fit” category of the reported practice  


Patient involvement
Patient safety theme the SCP/clinical risk management practice is aimed at
Reporting and learning systems involving patients.
Patients can be involved as partners in reporting the in-patient adverse events.
Objective of the CRM practice
There is evidence that patients represent a valuable source of reporting the adverse events in hospital [1, pg. 834].
Short description of the CRM practice, including any references for further information
Patients with at least one week hospitalisation were interviewed about the adverse events during the in-patient period. Data were compared to those reported by the hospital. The reporting system involving healthcare professionals included only 40% from the number of reported and validated adverse events from patients.
Patient with drug allergies are more likely to report them. [1]
Innovator of the SCP, country of origin
USA, study to justify the importance of involving patients in reporting adverse events in healthcare units
Involved health care staff
Any medical staff: doctors and nurses involved in reporting the incidents.
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
The survey was performed in the medical unit of a Boston teaching hospital to involve 228patients in the adverse event reporting. The patient reported adverse events was nearly 9 per 100 admissions. 4% of patients experienced near misses. [p.834, 1].
Summary of evidence for effectiveness, including references
Results from a prospective cohort study of 228 adult inpatients on a Boston medical unit showed that inpatients can identify adverse events affecting their care. [1]
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
Due to the fact that some adverse events are not included in the medical records, the hospital reporting system need to be complemented with information from the patient reports. [1]
Summary of available information on feasibility, including references
Study proves the efficiency of involving patients in reporting the adverse events, confronting the results with the information from the adverse event reported by healthcare professionals. [p.834, 1].
Existing implementation tools, including references
Potential for/description of patient involvement in the CRM practice, including references
Considering the fact that content of the fiche relies on the study to prove the efficiency of involving patients in reporting the adverse events, patient participation is the core content.
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1] Weingart, Saul; Pagovich, Odelya; Sands, Daniel; Li, Joseph; Aronson, Mark; ] Davis, Roger; Bates, David and Phillips, Russell (2005): What Can Hospitalized Patients Tell Us About Adverse Events? Learning from Patient-Reported Incidents. The Journal of General Internal Medicine.
Any additional information on the CRM (e.g. implementation barriers and drivers)