Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports

Abstract

Background Patient safety incident reports are a key source of safety intelligence. This study aimed to explore whether information contained in such reports can elicit facilitators of safety including responding, anticipating, monitoring, and learning and other mechanisms by which safety is maintained. The review further explored whether, if found, this information could be used to inform safety interventions. Methods Anonymised incident reports were obtained from two large teaching hospitals submitted between August and October 2020. The Systems Engineering Initiative for Patient Safety (SEIPS) tool and the resilience potentials (responding, anticipating, monitoring, and learning) frameworks guided thematic analysis. SEIPS was used to explore the components of people, tools, tasks and environments and the interactions between these that contribute to safety. The resilience potentials provided insight into healthcare resilience at an individual, team, and organisational level. Results Sixty incident reports were analysed. They included descriptions of all the SEIPS framework components. People used tools such as electronic prescribing systems to perform tasks within different healthcare environments that facilitated safety. All four of the resilient capacities were identified, mostly individuals and teams responding to events, however, monitoring, anticipation and learning were described for individuals, teams, and organisations. Conclusion Incident reports contain information about safety practices, much of which is not identified by traditional approaches such as root cause analysis. This information can be used to enhance enablers of safety and encourage greater proactive anticipation and system-level learning.