Establishing a global learning community for incident-reporting systems.

Journal: Quality & Safety In Health Care
Published:
Abstract

Background: Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation.

Conclusions: Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.

Authors
Julius Pham, Sebastiana Gianci, James Battles, Paula Beard, John Clarke, Hilary Coates, Liam Donaldson, Noel Eldridge, Martin Fletcher, Christine Goeschel, Eugenie Heitmiller, Jörgen Hensen, Edward Kelley, Jerod Loeb, William Runciman, Susan Sheridan, Albert Wu, Peter Pronovost