• S Kreckler, K Catchpole, P McCulloch, and A Handa.
• Oxford University, Nuffield Department of Surgery, John Radcliffe Hospital, Oxford, UK. simon.kreckler@nds.ox.ac.uk
• Qual Saf Health Care. 2009 Apr 1; 18 (2): 116-20.

ObjectivesTo evaluate the process of incident reporting in a surgical setting. In particular: the influence of event outcome on reporting behaviour; staff perception of surgical complications as reportable events.DesignAnonymous web-based questionnaire survey.SettingGeneral Surgical Department in a UK teaching hospital.PopulationOf 203 eligible staff, 55 (76.4%) doctors and 82 (62.6%) nurses participated.Main Outcome MeasuresKnowledge and use of local reporting system; propensity to report incidents which vary by outcome (harm, no harm, harm prevented); propensity to report surgical complications; practical and psychological barriers to reporting.ResultsNurses were significantly more likely to know of the local reporting system and to have recently completed a report than doctors. The level of harm (F(1.8,246) = 254.2, p<0.001), incident type (F(1.9,258) = 64.4, p<0.001) and profession (F(1,135) = 20.7, p<0.001) all significantly affected the likelihood of reporting. Staff were most likely to report an incident when harm occurred. Doctors were significantly less likely to report surgical complications than other types of incident (15% vs 53%, z = 4.633, p<0.001). Fear was a significantly less important barrier to reporting than other reasons (z = -3.49, p<0.0002).ConclusionAn incident is more likely to be reported if harm results. Surgical complications are not generally perceived to be "reportable incidents," but they are addressed in Mortality and Morbidity meetings (M&M). Integrating M&M and incident reporting data will result in more comprehensive healthcare safety systems.

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