Implications from China patient safety incidents reporting system

Figures & data

Figure 1 Annual distribution of the reports, by the grade of hospital.

Figure 2 Geographic distribution of the reports.

Table 1 The type of incident and the degree of patient harm (N=36,498)

Type of incident	Death	Severe	Moderate	Mild or no harm	Cannot define or data missing	Total
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Drug-related incidents	305 (3.5)	417 (4.8)	1,379 (15.8)	6,027 (69.2)	587 (6.7)	8,715 (100.0)
Nursing-related incidents	143 (1.9)	341 (4.6)	1,207 (16.2)	5,514 (73.9)	258 (3.5)	7,463 (100.0)
Surgery-related incidents	549 (9.2)	679 (11.4)	1,451 (24.4)	2,909 (48.8)	369 (6.2)	5,957 (100.0)
Medical procedure incidents	79 (2.0)	251 (6.5)	719 (18.5)	2,568 (66.0)	274 (7.0)	3,891 (100.0)
Tube-related incidents	59 (2.2)	157 (5.8)	513 (19.1)	1,786 (66.4)	174 (6.5)	2,689 (100.0)
Medical device-related incidents	77 (3.9)	71 (3.6)	517 (25.9)	1,109 (55.6)	220 (11.0)	1,994 (100.0)
Laboratory incidents	24 (1.6)	51 (3.3)	271 (17.5)	1,071 (69.2)	130 (8.4)	1,547 (100.0)
Unexpected incidents	47 (3.6)	59 (4.5)	257 (19.7)	804 (61.7)	136 (10.4)	1,303 (100.0)
Public accidents	9 (1.3)	21 (3.1)	103 (15.2)	515 (75.8)	31 (4.6)	679 (100.0)
Blood transfusion incidents	4 (0.7)	10 (1.7)	114 (19.4)	433 (73.8)	26 (4.4)	587 (100.0)
Anesthesia incidents	10 (2.5)	27 (6.7)	73 (18.0)	293 (72.2)	3 (0.7)	406 (100.0)
Other incidents	21 (1.7)	58 (4.6)	218 (17.2)	893 (70.5)	77 (6.1)	1,267 (100.0)
Total	1,327 (3.6)	2,142 (5.9)	6,822 (18.7)	23,922 (65.5)	2,285 (6.3)	36,498 (100.0)

Notes: Degree of harm: 1) Death: caused by patient safety event; 2) Severe: permanent or long-term harm; 3) Moderate: short-term harm and patient(s) required further treatment, or procedure; 4) Mild: minimal harm and patient(s) required extra observation or minor treatment.

Table 2 The possible contributing factors for the incident occurring (N=60,532, multiple reasons)

Type of incident	Patient factors	Staff factors	Environment factors	Medical factors	System failures	Others factors	Cannot define or data missing	Total
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
Drug-related incidents	1,375 (9.5)	6,648 (46.1)	313 (2.2)	1,675 (11.6)	3,216 (22.3)	374 (2.6)	817 (5.7)	14,418 (100.0)
Nursing-related incidents	2,935 (19.8)	4,795 (32.4)	2,191 (14.8)	1,501 (10.1)	2,417 (16.3)	515 (3.5)	437 (3.0)	14,791 (100.0)
Surgery-related incidents	519 (5.3)	5,079 (52.2)	–	1,753 (18.0)	1,391 (14.3)	719 (7.4)	277 (2.8)	9,738 (100.0)
Medical procedure incidents	1,091 (16.6)	1,715 (26.2)	–	631 (9.6)	2,789 (42.5)	215 (3.3)	116 (1.8)	6,557 (100.0)
Tube-related incidents	2,217 (36.0)	1,697 (27.6)	–	575 (9.3)	1,309 (21.3)	137 (2.2)	215 (3.5)	6,150 (100.0)
Medical device-related incidents	215 (8.1)	659 (25.0)	161 (6.1)	–	323 (12.2)	1,192 (45.1)	91 (3.4)	2,641 (100.0)
Laboratory incidents	154 (6.7)	1,347 (58.8)	63 (2.8)	–	575 (25.1)	95 (4.1)	56 (2.4)	2,290 (100.0)
Unexpected incidents	1,163 (64.4)	419 (23.2)	139 (7.7)	–	–	36 (2.0)	49 (2.7)	1,806 (100.0)
Public accidents	–	119 (14.7)	237 (29.3)	–	–	437 (54.0)	17 (2.1)	810 (100.0)
Blood transfusion incidents	–	475 (64.5)	–	–	217 (29.5)	37 (5.0)	7 (1.0)	736 (100.0)
Anesthesia incidents	167 (28.1)	341 (57.3)	–	36 (6.1)	42 (7.1)	9 (1.5)	0 (0.0)	595 (100.0)

Table 3 Work experience of medical staff and the degree of patient harm (N=28,192)

Work experience	Death	Severe	Moderate	Mild or no harm	Cannot define or data missing	Total
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
≤5 years	458 (3.7)	887 (7.1)	3,081 (24.6)	7,435 (59.4)	656 (5.2)	12,517 (100)
6–10 years	436 (5.7)	595 (7.7)	1,809 (23.5)	4,554 (59.0)	319 (4.1)	7,713 (100)
>10 years	373 (5.4)	571 (8.3)	1,525 (22.1)	4,073 (59.0)	361 (5.2)	6,903 (100)
Othersa	56 (5.3)	81 (7.6)	237 (22.4)	607 (57.3)	78 (7.4)	1,059 (100)
Total	1,323 (4.7)	2,134 (7.6)	6,652 (23.6)	16,669 (59.1)	1,414 (5.0)	28,192 (100)

Notes:

a Incidents involved multiple persons with various hierarchy of work experience; Degree of harm: 1) Death: caused by patient safety event; 2) Severe: permanent or long-term harm; 3) Moderate: short-term harm and patient(s) required further treatment, or procedure; 4) Mild: minimal harm and patient(s) required extra observation or minor treatment.

Figure S1 The working flowchart of NPSIRS.

Abbreviation: NPSIRS, National Patient Safety Incidents Reporting System.

Table S1 Detail specifications of incident type

Classification	Specification
Drug-related incidents	Any incident related to drug administration, prescribing, dispensing, delivery, monitoring, and patient’s refusal to take medication
Nursing-related incidents	Any incident related to the nursing, such as patient falling/tumble, missing, injury, suicide, bedsore, and nursing-associated nosocomial infection
Surgery-related incidents	Any incident related to surgical operation, including surgical incision infection
Medical procedure incidents	Any incident related to the clinical procedure, such as delay in treatment, delay in obtaining clinical assistance, failure to discontinue treatment, inappropriate patient handling, inappropriate treatment, delayed diagnosis, and misdiagnosis
Tube-related incidents	Any incident related to various tubes, such as unplanned endotracheal extubation, ventilators or central venous catheter-related infection, and complications with intubation
Medical device-related incidents	Any incident related to medical equipment, such as failure of device, lack of device, unavailability of device, user error, and wrong device used
Laboratory incidents	Any incident related to laboratory test procedure, such as specimens missing and failure in test results
Unexpected incidents	Any unexpected incident, such as cardiopulmonary arrest and other unpredictable events
Public accidents	Any incident occurred in public environment, such as waiting room
Blood transfusion incidents	Any incident related to blood transfusion, such as allergic reaction to a blood transfusion
Anesthesia incidents	Any incident related to anesthesia, such as anesthetic accident
Other incidents	Any incident that cannot be classified into above