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HealthOctober 12, 2020

The impact of anonymous incident reporting on institutional situational awareness

By: Sarah Handzel, BSN, RN
Healthcare facilities nationwide use incident reporting systems to disclose and document adverse events or near misses involving patients. These reporting systems have become a critical part of healthcare and are used to help draft policies and procedures intended to promote a culture of safety and increase positive patient outcomes.

There are many factors which play into how safe a specific institution is, and situational awareness may help prevent a significant number of medical errors. In general, situational awareness may be defined as how quickly and thoroughly a person understands events surrounding a patient, their available hospital resources, and which outcomes are most likely in the near future.1

But measuring situational awareness is challenging, and it isn’t certain how anonymous incident reporting (AIR) systems play into its development. Recently, a study in Quality Management in Health Care2 examined how one institution’s AIR system impacted situational awareness using statistical analysis of reports of surgical critical events.

Designing the study and implementing statistical process control

First, researchers gathered the study institution’s AIRs and surgical critical event reports occurring between 2012 and 2017. Critical events were tracked using the Veterans Affairs Surgical Quality Improvement Program’s (VASQIP) quarterly Critical Incident Tracking Notification (CITNS), which defines surgical critical events as:

  • Death in OR
  • Death from hemorrhage within 24 hours of surgery
  • Incorrect surgery
  • OR fire and OR burn
  • Retained surgical item

Then, statistical process control (SPC) was applied to the institution’s AIR system by graphing the number of reports per month over time in a control chart. Next, the graph was interpreted for special-cause variation (SCV), which represents effects external to a production process, and common-cause variation (CCV), which represents the inherent variability of a process.

Once the researchers noted a significant variation event, they studied the trend to determine its importance. Finally, they temporally related SCV and CCV with surgical critical events to identify any associations.

Improvements in situational awareness linked to AIR

After examining the data, the study team found that the highest number of CITNS occurred early in the self-reporting process at the institution. These events declined over time, and, eventually, the numbers of AIR were found to be inversely related to CITNS reports. The researchers concluded that this trend is expected in an institution making progress to improve situational awareness.

While the data did show a relationship between AIR and situational awareness, the authors note that assessments of AIRs must move away from linear outcomes, such as the number of reports generated, to an examination of the shared goal of improved situational awareness. Additionally, while the control chart was useful in this study, it is most effective in linear production models—and due to the complexity of healthcare itself, there are rarely linear outcomes that are measurable.

Improving an institution’s culture of safety and patient outcomes is a continuous process, and situational awareness is a critical component in this process. While AIR does help to improve situational awareness, institutions should continue to take steps to improve the quality of care offered to patients.

Sarah Handzel, BSN, RN
Freelance Health and Medical Content Writer, Wolters Kluwer Health
Sarah has over nine years’ experience in various clinical areas, including surgery, endocrinology, family practice, and pharmaceuticals. She began writing professionally in 2016 as a way to use her medical knowledge beyond the bedside to help educate and inform healthcare consumers and providers.
  1. Zysk, Terry. “Why Situational Awareness Is Critical for Hospitals and Healthcare Teams.” LiveProcess, 19 June 2019,
  2. “Studying Institutional Situational Awareness Through Anonymous Incident Reporting.” NursingCenter, 2020,
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