RT Journal Article
SR Electronic
T1 Establishing a global learning community for incident-reporting systems
JF Quality and Safety in Health Care
JO Qual Saf Health Care
FD BMJ Publishing Group Ltd
SP 446
OP 451
DO 10.1136/qshc.2009.037739
VO 19
IS 5
A1 Julius Cuong Pham
A1 Sebastiana Gianci
A1 James Battles
A1 Paula Beard
A1 John R Clarke
A1 Hilary Coates
A1 Liam Donaldson
A1 Noel Eldridge
A1 Martin Fletcher
A1 Christine A Goeschel
A1 Eugenie Heitmiller
A1 Jörgen Hensen
A1 Edward Kelley
A1 Jerod Loeb
A1 William Runciman
A1 Susan Sheridan
A1 Albert W Wu
A1 Peter J Pronovost
YR 2010
UL http://qualitysafety.bmj.com/content/19/5/446.abstract
AB 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.