Implementing an Intervention to Improve Physicians’ Incident Reporting in the Hospital Setting: A Pilot Study


  • Naomi Akiyama, PhD Iwate Medical University
  • Keisuke Koeda, MD, PhD Iwate Medical University
  • Ryuji Uozumi, PhD Kyoto University
  • Fumiaki Takahashi, PhD Iwate Medical University
  • Kuniaki Ogasawara, MD, PhD Iwate Medical University



patient safety, barrier to incident reporting,, doctor, intervention, pilot study


Objectives: To improve patient safety, information regarding errors must be collected. This practice constitutes one of the strategies that hospital managers use to understand the types of errors that occur at their hospitals. This pilot study aimed to evaluate an intervention designed to improve error reporting percentage among physicians.

Methods: The study was conducted at University Hospital A, where data were collected from April 2017 to March 2019. The intervention began in April 2018 and involved the following steps: receiving support and appropriate feedback from the hospital administrator, defining reporting standards, improving the incident reporting system, and having the hospital administrators set clear goals and begin a visualized feedback process. Physicians were the main target for these steps in this study.

Results: The percentage of reports submitted by physicians relative to nonphysicians increased from fiscal year (FY) 2017 to FY 2018, with the largest monthly increase within 2018 occurring in November. Physician reporting was higher in FY 2018 than in FY 2017, with the greatest difference observed for December of the respective FYs (p < 0.001, analyzed using Fisher’s exact test). The percentage of reports submitted by physicians increased by 2.6% (95% confidence interval [CI]: 1.7, 3.5) from FY 2017 to FY 2018, raising the percentage to 9%.

Conclusions: Based on these results, it can be said that the intervention effectively increased incident reporting among not only physicians but also nonphysician staff members. In this regard, reporting barriers were broken when hospital administrators encouraged staff to submit incident reports. Active feedback by hospital administrators—the executive class of the hospital—may encourage not only physicians, but also staff members to submit incident reports, thus effectively removing reporting barriers.

Author Biographies

Naomi Akiyama, PhD, Iwate Medical University

Naomi Akiyama ( ) is a lecturer at the School of Nursing, Gifu University of Health Science. She received her doctorate in health science from Tokyo University in 2011 and focuses her research on the field of patient safety and public health. She received the Patient Safety Award from Healthcare Safety and the Excellent Presentation Award at the 3rd Academic Meeting of the Academy of Nursing Evaluation. She hopes to continue her work on patient safety in Japan.

Keisuke Koeda, MD, PhD, Iwate Medical University

Keisuke Koeda is affiliated with the Department of Medical Safety Science at Iwate Medical University School of Medicine.

Ryuji Uozumi, PhD, Kyoto University

Ryuji Uozumi is a biostatistician in the Department of Biomedical Data Science at Stanford Medicine and an assistant professor in the Department of Biomedical Statistics and Bioinformatics at Kyoto University Graduate School of Medicine.

Fumiaki Takahashi, PhD, Iwate Medical University

Fumiaki Takahashi is a professor in the Division of Medical Engineering, Department of Information Science at Iwate Medical University and assistant department head of the Division of Biomedical Information Analysis at the Iwate Tohoku Medical Megabank Project.

Kuniaki Ogasawara, MD, PhD, Iwate Medical University

Kuniaki Ogasawara is a professor and chair in the Department of Neurosurgery at Iwate Medical University School of Medicine. His research focus is on cerebrovascular diseases, and he has published many papers related to changes of cognition and cerebral hemodynamics after surgery.


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How to Cite

Akiyama, N., Koeda, K., Uozumi, R., Takahashi, F., & Ogasawara, K. (2022). Implementing an Intervention to Improve Physicians’ Incident Reporting in the Hospital Setting: A Pilot Study . Patient Safety, 4(1), 18–25.



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