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Error management
Establishing a global learning community for incident-reporting systems
  1. Julius Cuong Pham1,
  2. Sebastiana Gianci2,
  3. James Battles3,
  4. Paula Beard4,
  5. John R Clarke5,
  6. Hilary Coates6,
  7. Liam Donaldson7,
  8. Noel Eldridge8,
  9. Martin Fletcher9,
  10. Christine A Goeschel10,
  11. Eugenie Heitmiller11,
  12. Jörgen Hensen12,
  13. Edward Kelley13,
  14. Jerod Loeb14,
  15. William Runciman15,
  16. Susan Sheridan16,
  17. Albert W Wu17,
  18. Peter J Pronovost18
  1. 1The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  2. 2World Health Organization, World Alliance of Patient Safety, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  3. 3Agency for Healthcare Research and Quality, Rockville, Maryland, USA
  4. 4Canadian Patient Safety Institute, Edmonton, Canada
  5. 5Drexel University, ECRI Institute, Plymouth Meeting, Pennsylvania, USA
  6. 6Royal College of Surgeons, Dublin, Ireland
  7. 7World Alliance for Patient Safety, Geneva, Switzerland
  8. 8Veterans Health Administration, Washington, District of Columbia, USA
  9. 9National Patient Safety Agency, London, UK
  10. 10The Johns Hopkins University Schools of Medicine, Nursing and Public Health, Baltimore, Maryland, USA
  11. 11The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  12. 12National Board of Health, Copenhagen, Denmark
  13. 13World Health Organization, Geneva, Switzerland
  14. 14The Joint Commission, Oakbrook Terrace, Illinois, USA
  15. 15Australian Patient Safety Foundation, Adelaide, Australia
  16. 16Consumers Advancing Patient Safety, Chicago, Illinois, USA
  17. 17The Johns Hopkins University Schools of Medicine and Public Health, Baltimore, Maryland, USA
  18. 18The Johns Hopkins University Schools of Medicine, Public Health and Nursing, Baltimore, Maryland, USA
  1. Correspondence to Dr Julius Cuong Pham, The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231, USA; jpham3{at}jhmi.edu

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.

  • Incident-reporting systems
  • patient safety
  • risk management
  • medical mistakes
  • safety reporting systems
  • medical error
  • qualitative research

https://doi.org/10.1136/qshc.2009.037739

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    Footnotes

    • Funding The WHO World Alliance for Patient Safety (WAPS) did not directly influence the meeting agenda, the drafting of the manuscript or the content of the manuscript.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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