The mismatch between principles and practices of incident reporting
| Key principles in other industries | Common practices in healthcare |
|---|---|
| Focus on reporting incidents that provide serious, specific or surprising insights into system safety | Encourage reporting of any and all incidents that may in some way relate to safety concerns |
| Avoid swamping the reporting system to ensure thorough review of all reported incidents | Celebrate large quantities of incident reports and aim for ever-increasing overall reporting rates |
| Use incident reports to identify and prioritise significant, new or emerging risks | Quantify, count and chart different categories of incident report to monitor performance trends |
| Harness the social processes of reporting to generate increased awareness and reporting of current risks | Aim to increase reporting rates to address perceived epidemiological or statistical biases in reported data |
| Expect reports to be inaccurate and incomplete; focus on investigation as the means of obtaining complete picture | Improve accuracy of incident reports through more comprehensive data collection processes |
| Apply pragmatic incident taxonomies that support basic analysis, improvement action and retrospective search | Expect incident taxonomies to accurately explain and map complex realities |
| Ensure incident reporting systems are managed and coordinated by an operationally independent group | Incidents reported to direct supervisors or other operational managers within organisation |
| Reporting constitutes one component of broad range of conversations and activities focused on safety and risk | Incident reporting represents the most visible safety activity for many organisations |
| Create regimes of mutual accountability for improvement and peer review of actions around incidents | Use reported incident data as an indicator to monitor organisational safety performance |