The problem with incident reporting

BMJ Quality and Safety

Volumn 25, Issue 2, 2016, Pages 71-75

  Macrae, Carl ^a  

^a NONE

Author keywords

[No Author keywords available]

Indexed keywords

AIRCRAFT; HEALTH CARE QUALITY; HEALTH CARE SYSTEM; HUMAN; INCIDENT REPORT; PATIENT SAFETY; REVIEW; HEALTH CARE DELIVERY; NEEDS ASSESSMENT; ORGANIZATION AND MANAGEMENT; PROCEDURES; RISK MANAGEMENT; SAFETY; UNITED KINGDOM;

DELIVERY OF HEALTH CARE; HUMANS; NEEDS ASSESSMENT; PATIENT SAFETY; QUALITY OF HEALTH CARE; RISK MANAGEMENT; SAFETY MANAGEMENT; UNITED KINGDOM;

EID: 84955274720     PISSN: 20445415     EISSN: None     Source Type: Journal    
DOI: 10.1136/bmjqs-2015-004732     Document Type: Review

References (38)

1. Kohn LT, Corrigan JM, Donaldson MS. To err is human. Institute of Medicine, 1999.
2. Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. London: Department of Health, 2000.
3. Doupi P. National reporting systems for patient safety incidents: a review of the situation in Europe. Helsinki: National Institute for Health and Welfare, 2009.
4. Bromiley M. Have you ever made a mistake? RCoA Bulletin 2008;48:2442-5.
5. National Patient Safety Agency. Haemodialysis patients: risks associated with water supply (hydrogen peroxide). NPSA, 2008. http://www.nrls.npsa.nhs.uk/ resources/?EntryId45=59893 (accessed 18 Aug 2012).
6. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013.
7. Kirkup B. The Report of the Morecambe Bay Investigation. London: The Stationery Office, 2015.
8. Shojania KG. The frustrating case of incident-reporting systems. Qual Saf Health Care 2008;17:400-2.
9. Thomas M, Schultz TJ, Hannaford N, et al. Mapping the limits of safety reporting systems in health care-what lessons can we actually learn. Med J Aust 2011;194:635-9.
10. Minogue WF. Error reporting: patient safety's weakest link. Am J Med Qual 2005;20:295-6.
11. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320:759-63.
12. National Patient Safety Agency. Seven steps to patient safety: the full reference guide. London: NHS National Patient Safety Agency, 2004.
13. Donaldson L. When will health care pass the orange-wire test? Lancet 2004;364:1567-8.
14. Macrae C. Close calls: managing risk and resilience in airline flight safety. London: Palgrave, 2014.
15. Aspden P, Corrigan JM, Wolcott J, et al. Patient safety: achieving a new standard for care. Institute of Medicine, National Academies Press, 2004.
16. Civil Aviation Authority. The mandatory occurrence reporting scheme: CAP 382. London: Civil Aviation Authority, 2011.
17. Hutchinson A, Young TA, Cooper KL, et al.Trendsinhealthcare incident reporting and relationship to safety and quality data in acute hospitals: results from the National Reporting and Learning System. Qual Saf Health Care 2009;18:5-10.
18. National Reporting and Learning System. NRLS quarterly data workbook. 2014. http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/?entryid45=135410 (accessed 26 Jul 2015).
19. Billings C. Lessons learned from incident reporting in aviation. In: Cook RI, Woods DD, Miller C, eds. A tale of two stories: contrasting view of patient safety. Boston, MA: National Health Care Safety Council of the National Patient Safety Foundation, 1998.
20. Vincent C. Incident reporting and patient safety. BMJ 2007;334:51.
21. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health care's ability to quantify and accurately measure harm reduction. J Patient Saf 2010;6:247-50.
22. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care 2002;11:15-18.
23. Noble DJ, Panesar SS, Pronovost PJ. A public health approach to patient safety reporting systems is urgently needed. J Patient Saf 2011;7:109-12.
24. World Health Organisation. Conceptual framework for the international classification for patient safety. Final Technical Report. WHO, 2009.
25. Macrae C. Early warnings, weak signals and learning from healthcare disasters. BMJ Qual and Saf 2014;23:440-5.
26. Macrae C, Vincent C. Learning from failure: the need for independent safety investigation in healthcare. J R Soc Med 2014;107:439-43.
27. House of Commons Public Administration Select Committee. Investigating clinical incidents in the NHS. London: The Stationery Office, 2015.
28. Department of Health. Learning not blaming. London: Department of Health, 2015.
29. Vincent CA. Analysis of clinical incidents: a window on the system not a search for root causes. Qual Saf Health Care 2004;13:242-3.
30. Macrae C. Learning from patient safety incidents: creating participative risk regulation in healthcare. Health Risk Soc 2008;10:53-67.
31. Hewitt TA, Chreim S. Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting. BMJ Qual and Saf 2015;24:303-10.
32. Farley DO, Haviland A, Champagne S, et al. Adverse-event-reporting practices by US hospitals: results of a national survey. Qual Saf Health Care 2008;17:416-23.
33. Benn J, Koutantji M, Wallace L, et al. Feedback from incident reporting: information and action to improve patient safety. Qual Saf Health Care 2009;18:11-21.
34. Macrae C. Making risks visible: Identifying and interpreting threats to airline flight safety. J Occup Organ Psychol 2009;82:273-93.
35. Wenger E. Communities of practice: learning, meaning and identity. Cambridge: Cambridge University Press, 1998.
36. National Patient Safety Foundation. RCA2: improving root cause analyses and actions to prevent harm. Boston, MA: National Patient Safety Foundation, 2015.
37. Department of Health. Culture change in the NHS - applying the lessons of the Francis inquiries. London: Department of Health, 2015.
38. Dodds A, Kodate N. Understanding institutional conversion: the case of the National Reporting and Learning System. J Public Policy 2012;32:117-39.