Establishing a global learning community for incident-reporting systems. Issue 5 (25th October 2010)

• Record Type: Journal Article
• Authors: Pham, Julius Cuong; Gianci, Sebastiana; Battles, James; Beard, Paula; Clarke, John R; Coates, Hilary; Donaldson, Liam; Eldridge, Noel; Fletcher, Martin; Goeschel, Christine A; Heitmiller, Eugenie; Hensen, Jörgen; Kelley, Edward; Loeb, Jerod; Runciman, William; Sheridan, Susan; Wu, Albert W; Pronovost, Peter J
• Is Part Of: Quality & safety in health care. Volume 19:Issue 5(2010)
• Page Start: 446
• Page End: 451
• Publication Date: 2010-10-25
• Subjects: Incident-reporting systems -- patient safety -- risk management -- medical mistakes -- safety reporting systems -- medical error -- qualitative research
• DOI: 10.1136/qshc.2009.037739
• Languages: English
• ISSNs: 1475-3898

Abstract

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. Discussion: 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.