Establishing a global learning community for incident-reporting systems

TLDR

Incident‑reporting systems capture snapshots of hazards, mistakes, and system failures in healthcare and are a cornerstone of patient safety, yet they remain fragmented and isolated compared to other high‑risk industries. This article presents expert‑driven guidance on methods to identify, analyze, prioritize incidents, mitigate hazards, and evaluate risk reduction. In 2008, patient safety experts from eight countries convened to form a global community, leveraging their experience managing large incident‑reporting systems to advance the science of learning from mistakes.

Abstract

<h3>Background</h3> 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. <h3>Discussion</h3> 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.