ObjectiveThis study explored healthcare quality issues affecting the reporting and
investigation levels of digital incident reporting systems.MethodsA total of 38 health information technology-related incident reports
(free-text narratives) were collected from one of Sweden's national incident
reporting repositories. The incidents were analysed using an existing
framework, i.e., the Health Information Technology Classification System, to
identify the types of issues and consequences. The framework was applied in
two fields, ‘event description’ by the reporters and ‘manufacturer's
measures’, to assess the quality of reporting incidents by the reporters.
Additionally, the contributing factors, i.e., either human or technical
factors for both fields, were identified to evaluate the quality of the
reported incidents.ResultsFive types of issues were identified and changes made between
before-and-after investigations: Machine to software-related issues
(n=  8), machine to use-related issues
(n=  5), software to software-related issues
(n=  5), use to software-related issues
(n=  4) and use to use-related issues
(n=  1). Over two-thirds (n=  15)
of the incidents demonstrated a change in the contributing factors after the
investigation. Only four incidents were identified as altering the
consequences after the investigation.ConclusionThis study shed some light on the issues of incident reporting and the gap
between the reporting and investigation levels. Facilitating sufficient
staff training sessions, agreeing on common terms for health information
technology systems, refining the existing classifications systems, enforcing
mini-root cause analysis, and ensuring unit-based local reporting and
standard national reporting may help bridge the gap between reporting and
investigation levels in digital incident reporting.