TableĀ 1

The mismatch between principles and practices of incident reporting

Key principles in other industriesCommon practices in healthcare
Focus on reporting incidents that provide serious, specific or surprising insights into system safetyEncourage 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 incidentsCelebrate large quantities of incident reports and aim for ever-increasing overall reporting rates
Use incident reports to identify and prioritise significant, new or emerging risksQuantify, 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 risksAim 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 pictureImprove accuracy of incident reports through more comprehensive data collection processes
Apply pragmatic incident taxonomies that support basic analysis, improvement action and retrospective searchExpect incident taxonomies to accurately explain and map complex realities
Ensure incident reporting systems are managed and coordinated by an operationally independent groupIncidents 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 riskIncident reporting represents the most visible safety activity for many organisations
Create regimes of mutual accountability for improvement and peer review of actions around incidentsUse reported incident data as an indicator to monitor organisational safety performance