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Patient safety incident reporting: a qualitative study of thoughts and perceptions of experts 15 years after ‘To Err is Human
  1. Imogen Mitchell1,
  2. Anne Schuster2,
  3. Katherine Smith3,
  4. Peter Pronovost4,
  5. Albert Wu2
  1. 1Harkness Fellow, Commonwealth Fund, Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
  2. 2Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  3. 3Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
  4. 4Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Hospital, Baltimore, Maryland, USA
  1. Correspondence to Dr Imogen Mitchell, Medical School, Australian National University, Canberra, ACT 2605, Australia; imogen.mitchell{at}


One of the key recommendations of the Institute of Medicine's (IOM) report, To Err is Human, 15 years ago was for greater attention to incident reporting in healthcare, analogous to the role it has played in aviation and other high-risk industries. With the passage of time and maturation of the patient safety field, we conducted semistructured interviews with 11 international patient safety experts with knowledge of the US healthcare and meeting at least one of the following criteria: (1) involved in the development of the IOM's recommendations, (2) responsible for the design and/or implementation of national or regional incident reporting systems, (3) conducted research on patient safety/incident reporting at a national level. Five key challenges emerged to explain why incident reporting has not reached its potential: poor processing of incident reports (triaging, analysis, recommendations), inadequate engagement of doctors, insufficient subsequent visible action, inadequate funding and institutional support of incident reporting systems and inadequate usage of evolving health information technology. Leading patient safety experts acknowledge the current challenges of incident reports. The future of incident reporting lies in targeted incident reporting, effective triaging and robust analysis of the incident reports and meaningful engagement of doctors. Incident reporting must be coupled with visible, sustainable action and linkage of incident reports to the electronic health record. If the healthcare industry wants to learn from its mistakes, miss or near miss events, it will need to take incident reporting as seriously as the health budget.

  • Adverse events, epidemiology and detection
  • Significant event analysis, critical incident review
  • Patient safety
  • Qualitative research

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