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‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution. The series is overseen by Ken Catchpole (Guest Editor) and Kaveh Shojania (Editor-in-Chief).
Seminal reports that launched the modern field of patient safety highlighted the importance of learning from critical incidents.1 ,2 Since then, incident reporting systems have become one of the most widespread safety improvement strategies in healthcare, both within individual organisations and across entire healthcare systems.3
There are some strong examples of learning and improvement following serious patient safety incidents.4 ,5 But major disasters have also revealed widespread failures to understand and respond to reported safety incidents.6 ,7 Between these two extremes exists a range of frustrations and confusions regarding the purpose and practice of incident reporting.8–10 These problems can be traced to what was lost in translation when incident reporting was adapted from aviation and other safety-critical industries,11 with fundamental aspects of successful incident reporting systems misunderstood, misapplied or entirely missed in healthcare. This mistranslation of incident reporting from other industries has left us with confused and contradictory approaches to reporting and learning, seriously limiting the impact of this potentially powerful safety improvement strategy.
From orange wires to filing cabinets
The original ambitions for incident reporting in healthcare were deceptively simple. Staff would identify and report problems and mishaps; patient safety risks would be investigated and addressed and the resulting lessons would be widely shared and implemented.12 A powerful symbol of this ambition was the ‘orange wire’.13 Successful patient safety incident reporting systems would support system-wide learning in the same way that the discovery of a defective ‘orange wire’ in a particular aircraft type might cause rapid and systematic action across …
Competing interests CM declares consultancy in patient safety for NHS and other healthcare organisations. More recently, CM acted as an advisor to the Public Administration Select Committee inquiry into the investigation of clinical incidents in the NHS, and is a member of the Independent Patient Safety Investigation Service expert advisory group.
Provenance and peer review Not commissioned; internally peer reviewed.