Requisites for Successful Incident Reporting in Resilient Organisations

An International Perspective on Definitions and Terminology Used to Describe Serious Reportable Patient Safety Incidents: A Systematic Review

“…48 Barriers identified in the international literature include the following: lack of training in the use of incident reporting systems, lack of user-friendliness of preexisting systems, uncertainties around reportable incidents, organizational culture of blame, bureaucracy, fear of negative repercussions, lack of feedback, perceived lack of learning, and absence of change in practice as a result of incident reporting. [49][50][51] These barriers can be addressed using various strategies. A worked example is a case-based 60minute discussion and analysis of patient safety incidents delivered to 1169 National Health Service stakeholders in the UK.…”

“…Identifying and addressing barriers to learning from incident reporting are vital to the reporting of serious patient safety incidents 48 . Barriers identified in the international literature include the following: lack of training in the use of incident reporting systems, lack of user-friendliness of preexisting systems, uncertainties around reportable incidents, organizational culture of blame, bureaucracy, fear of negative repercussions, lack of feedback, perceived lack of learning, and absence of change in practice as a result of incident reporting 49–51 . These barriers can be addressed using various strategies.…”

High Reliability Organisations: Making Care Safer through Reliability and Resilience

“…There are a staggering number of incidents reported every year. However, despite the large number of potential learning opportunities, questions have been raised about the effectiveness of incident reporting systems to contribute to improvements in patient safety [19,[66][67][68][69]. There are now many studies that document barriers to effective incident reporting in health care.…”

Organisational reporting and learning systems: Innovating inside and outside of the box

“…The system dynamics can be visualised as shown in Figure 1, where resilient forms of behaviour support maintaining control of care delivery in the face of disruptive forces, such as lack of equipment or inadequate staffing levels. 17 Both, PRIMO and Errordiary lend themselves to providing insights about how healthcare professionals deliver safe care in the face of disturbances and disruptions. Within PRIMO, the narratives that staff submit often contain not only descriptions of hassle, but also descriptions of how staff coped with the hassle.…”

“…Barriers include lack of training in the use of incident reporting, usability problems of the systems that are used for reporting, uncertainty about what constitutes a reportable incident, blame culture and fear of consequences, lack of feedback and the absence of learning relevant to local practices. [14][15][16][17] A major weakness of many incident reporting systems in the NHS is that they produce little actual change. 18 The perceived lack of learning and absence of relevance to the local work environment may have a detrimental impact on the willingness of staff to contribute to incident reporting.…”