Article

Establishing a global learning community for incident-reporting systems.

The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231, USA.
Quality and Safety in Health Care (Impact Factor: 2.16). 10/2010; 19(5):446-51. DOI: 10.1136/qshc.2009.037739
Source: PubMed

ABSTRACT BACKGROUND: Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation. DISCUSSION: Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.

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