Regular multidisciplinary departmental meetings to discuss lessons learnt from reporting

Regular monthly department safety bulletin that includes a fixed reminder of the unit’s agreed trigger list, summary of previous month’s critical incident reports, data on admissions and activity levels and a clinical lesson or guideline of the month

Individual email bulletins, paper-based newsletters or bulletins posted on department website

Targeted campaigns aimed at a specific incident or pattern of incidents

Investigation of reported incidents and identified safety issues through Root Cause Analysis (retrospective) and Failure Modes and Effects Analysis (prospective) methods to identify system failures for remedial action

Feedback notes system developed as an educational tool to provide information on incident, equipment involved, causes and triggers uncovered by investigation, lessons learnt and positive actions taken by staff to minimise adverse consequences

Feedback notes highlight positive actions taken by staff and provide anonymous information that allows staff to learn from why an incident occurred, in a supportive manner, while promoting a culture that supports learning

Feedback notes issued to ward link nurses, used in teaching sessions and information disseminated to other hospital departments through annual nurse clinical update sessions and hospital intranet

Report submitters, upon reporting to the system, receive reminders, composite data or commentary to encourage a two-way flow of information

Weekly or monthly newsletters that identify recent errors, their associated hazards and hazard control strategies

Presentation of aggregated error data to clinic administrators and care givers so that they can implement useful error or hazard prevention strategies

Educational information provided to patients so that they understand their role in helping to prevent errors

Automatic feedback of all reported incidents to local organisational quality managers and morbidity and mortality coordinators

Automated analysis and secure transmission of performance data back to reporting clinician, who has personal access to tracked data

Professional groups, colleges and specialist associations can apply for access to data at suitable levels of aggregation for use in monitoring training performance, for example

Feedback of issue progress by email to individual reporter and direct feedback of follow-up actions taken to original reporter to “close the loop”

Monthly article in staff bulletin to highlight safety issues

Safety improvements published quarterly in hospital newsletter

Monthly email circulated to front-line staff (anyone that reported) with summary of improvements made

Weekly reports of overdue follow-up on safety reports for nurse senior directors

Monthly patient safety leadership walkround visits

Quarterly report to higher levels of organisation including summary of actions taken to hospital leadership

Production of safety improvement actions and recommendations for follow-up, including prioritisation of opportunities and actions, assigning responsibility and accountability, and implementing the action plan

Monthly report sent to each participating ICU including quantitative data concerning the number of reports submitted in previous month compared with past year and individualised site data compared with data from across all study sites

Monthly feedback is used by ICU site team to identify local areas for improvement and each site receives text descriptions and system factors for all the incidents reported at the site, plus data on total events to date, types of events reported and types of providers reporting for use at morbidity and mortality conferences, patient safety committees, hospital risk-management and hospital quality-improvement processes

Principal investigators at each site have the capability to access and query data submitted from their site for local analysis and to generate reports for use in quality-improvement activities using data analysis wizard

Information sharing with front-line staff is promoted through use of staff bulletin board postings which accompany each monthly newsletter and which contain a summary of a safety issue raised, textual case examples, system failures identified and specific actions that may be taken to address them

Quarterly newsletter is distributed to staff at all study sites containing details of the project’s activities, focuses upon a common safety problem each issue and includes tips for improving safety in order to encourage learning across institutions

Systems solutions and improvements developed in a timely and efficient manner to address process and systems gaps identified through analysis of how, when, why and where incidents occurred

Follow-up actions are tracked by the IT system, which streamlines the data-management and risk-identification process allowing more time for the design and implementation of improvement initiatives

User-controllable ad hoc querying of incident database and generation of reports

Educational feedback to enhance safety awareness through use of case studies outlining hospital-system successes and failures

Continuous communication with hospital staff through regular newsletters and department meetings to communicate patient safety data and what was being done with the data

Feedback of aggregate data to staff as well as specific case follow-up

Mechanisms for quality managers to validate reports and to track the completion of specific actions associated with a validated issue are built into the IT system that handles the report

Incidents and successful actions taken to resolve them are archived within the database

Time taken to resolve outstanding quality issues is used as a metric to indicate level of risk to the organisation

Implementation of urgent improvement actions for high risk issues within a predetermined timescale

Patient safety seminars three times a year to inform all staff of findings from reporting systems and support a hospital-wide safety culture

Targeted staff education programmes linked to professional accreditation scheme

Ward rounds by peers and safety committee members to check safety improvements have been implemented

Safety-feedback information is made available to staff through hospital intranet, clinical risk manager’s monthly meetings (cascade) and mailing list

Paper-based and web-based newsletter alerts with topics chosen to coincide with media coverage of serious events, and content includes commentary by hospital experts on specific issues

Data from incident reports are used to investigate specific incidents in individual hospitals and contribute to summary profiles of types of incidents that take place across all institutions

Benchmark data relating to frequency of incident types occurring are produced for comparison across institutions of similar bed size and comparison against system-wide averages to help identify problem areas

Incident reports are reviewed by hospital risk manager and administrator in charge of the unit, who can take immediate action

Incident reports are also passed to safety and quality-assurance committee for in-depth analysis and corrective action against safety problems, including the development of guidelines for hospital practice and governing the use of equipment, as well as nursing policy and changes to the equipment used in certain procedures

Assessment and monitoring of the effectiveness of corrective measures are undertaken and the safety process reviewed where there is evidence of repeated incidents

Further investigations of specific problem areas (identified through above average incident rates) are undertaken in specific institutions

Quarterly incident report summary generated for all participating hospitals

System owner within hospital department screens received incident reports regularly to identify those requiring immediate action

Safety actions are discussed at monthly multidisciplinary clinical governance meetings

Monthly newsletter details all the incidents of the month, by category, in abbreviated narrative form

Extended, annual presentation regarding operation of the reporting system and reported incidents is made to the local anaesthetic department

Disciplinary action and mandatory re-education undertaken where considered necessary in accordance with a fair policy to ensure required standards of compliance and competence

Summary reports of reported errors with causes presented to all department managers and at unit meetings as an educational tool

Medication safety coordinators discuss implications for improving safety with individual departments on a weekly basis, and ad hoc work groups are formed to troubleshoot problems

Local on-site managers take immediate action to ensure patient safety and notify department/unit management and risk-management upon occurrence of incidents that resulted in actual harm

Specific follow-up process and actions implemented according to incident policy and severity classification scheme linked to specific levels of action

Information from reported errors is used to implement improvements in the medication administration process, to support pharmacist education programmes and to support inclusion of safe practices in the design of new computerised physician order entry systems

Recommendations for monitoring new systems or processes to ensure that, once implemented, they continue to be effective

Safety case management committee disseminates lessons learnt documents and action plans to higher-level authorising bodies (clinical executive board), a performance improvement committee and various other clinical committees and specialist bodies

Changes implemented in clinical systems, processes or policy revisions

Patient or clinician education campaigns

Monitoring of clinical systems or processes

Clinical communications produced

Staffing adjustment or supervision

Direct action taken by nursing managers to ensure rapid patient safety improvement in response to reported issues

On-line event reporting tool allows nurses to share experiences of how they have improved patient safety in their units based upon directly actionable data provided by reporting system, ensuring widespread improvements across individual organisations

Nurse managers receive immediate, real-time notification of safety events on their units

Managers can run their own local-incident trend analysis reports

Identification of problems and contributory factors through incident monitoring for further investigation towards development and implementation of appropriate interventions to improve quality of care

Preventive strategies devised on the basis of potential severity of impact and frequency of occurrence of contributory factors, as well as follow-up risk–benefit analysis to justify the resources used

Analysis of 2000 reported incidents in anaesthesia were published in 30 articles by 1992

Development of national standards and guidelines governing aspects of clinical practice, including equipment use and further monitoring of specific issues

Use of reported incident data to clarify and support problems identified with clinical equipment, leading to recall and modification of affected devices

De-identified data comparable across institutions and units

AIMS 2 web system employs cue-based retrieval that allows the user to rapidly retrieve a broad range of relevant incident reports

Newsletters, publications and advice at national level, feedback of improvement actions and evidence of action occurs at local level

Brief summary information sheet “Hot Spots” is produced each month for nursing units containing information on trends in incident data along with opportunities for improvement

Improvement of medication administration policies to reduce causes of error undertaken based upon issues raised through reporting system

Immediate response to occurrence of a medication administration incident, when required

Mandatory medication error education programme was implemented for nursing and medical staff using examples of different incident types reported to hospital system

Personal study modules with written tests on local medication administration procedures are given in cases where training needs are identified from incidents

Monthly reports from the incident database are generated to help identify problem areas according to severity-rated reports and categorisation according to unit of origin, error type, system breakdown and drug category

Various forums and committees are responsible for reviewing medication error data to identify opportunities for improving patient care both within and across departments, including a quality-assurance committee which produces recommendations for physician’s practice, a pharmacy committee that addresses hospital-wide medications policy and a medication-error task force for specific issues

Interventions are implemented on the basis of quality-improvement opportunities identified by the committees

Disciplinary action taken against staff, where necessary, including: termination, counselling, suspension or written reprimand

Staff safety issues are resolved through training or changes in shifts, tasks or assignments

Where clinical interventions are required, system changes include: development of behaviour change plans, new goal determinations or medications review

Facility repairs or restructuring is undertaken in response to reported health and safety issues relating to building maintenance and design

Actions for operations management include protocol changes, new monitoring forms and new committee formation

Further monitoring/baseline data gathering to support systems improvement decisions

Communication reports are circulated immediately following an incident to notify all relevant departments of the basic details of the event and the corrective actions that have been taken

Specialty-based centralised incident reporting, analysis and feedback processes to promote multidisciplinary, multi-institutional collaborative learning using data to support systems improvement

Periodic structured feedback of collected errors to participating institutions and through biannual meetings

Data fed into numerous local patient safety improvement projects

Multidisciplinary teams prepared poster presentations using case studies of patient safety issues within their units for sharing at collaborative meetings

Monthly interrogation of trust incident database and report sent to A&E clinical risk-management committee, which discusses reported incidents once a month and assigns actions

Immediate response made to serious untoward incidents which are also escalated for review in a separate process at A&E risk-management meeting

Newsletters are circulated to staff including summary of learning points and highlighting new policies introduced as a result of safety issue analysis

Systems improvements including changes to working practices and equipment use implemented based upon cluster analysis of reported incidents

Educational feedback to rural primary-care practices based upon collection and analysis of medical-error data

Implementation of interventions to improve patient safety: Principles for Process Improvement were developed for each identified safety area and focused upon processes which were amenable to assessment and improvement

Follow-up interviews scheduled with reporting staff, where necessary, to elicit further information

Clinical steering group met in order to review data, direct additional study and create policy. Learning groups set up, comprising personnel from practices and project staff, in order to develop recommendations to tackle specific safety issues identified through reporting system data

For serious threats to patient safety, electronic and hard copy “alerts” were issued to all participants, briefly describing the event and recommendations developed to reduce the potential for that type of event

Periodic newsletter issued to practices

Practice-specific (individualised) recommendations were made for specific patient safety issues

Telephone hotline for reporting incidents and near misses, providing real-time dialogue with reporter to provide support, elaborate upon reported information and provide incident debriefing by professionals to ensure lessons are learnt on an individual level

Targeted training programmes implemented on the basis of analysis of single and multiple events

Alteration of working practices and introduction of error reducing measures to ensure organisational learning based upon investigation of single incidents and analysis of data from multiple incidents

Manual on error prevention using practical examples of clinical adverse events