Incident Reporting and Severity-Weighted Safety Learning in an Adult Regional Burn Center: A Five-Year Review

Abstract

Voluntary incident-reporting systems are widely used in hospitals, but their value depends on classification quality, review processes, linkage to complementary safety pathways, and translation into learning. Burn centers are vulnerable to fragmented safety intelligence because care spans resuscitation, critical care, surgery, wound management, rehabilitation, reconstruction, and outpatient follow-up. We reviewed institutional incident reports assigned to an adult regional burn center from April 1, 2021, to March 31, 2026. The dataset contained 1,418 reports. The most frequent categories were specimen or laboratory events, medication or fluid events, safety, security, or miscellaneous events, and pressure injuries. Harm level was not visible in structured form in 811 reports (57.2%). This absence was patterned: 546 of 547 specimen or laboratory reports and all 130 pressure-injury reports lacked visible structured harm classification. Pressure-injury stage or category was not reliably available in the analytic extract and was not imputed as a surrogate for harm. Among 607 reports with specified harm level, 16 were moderate and 4 severe. Severity-weighted review changed interpretation: infection prevention and control accounted for only 17 reports overall but 14 of 20 moderate or severe harm reports. Narrative follow-up was present in most high-harm reports, but structured contributing factors were absent in 17 of 20. Incident reporting should be one input into a severity-weighted burn-center learning system with harm classification at review or closure, escalation, action ownership, implementation resources, documented closure, and feedback to frontline teams.