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Learning from excellence in healthcare: a new approach to incident reporting
  1. Nicola Kelly1,
  2. Simon Blake1,2,
  3. Adrian Plunkett1
  1. 1PICU, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
  2. 2Warwick Business School, Coventry, UK
  1. Correspondence to Dr Adrian Plunkett, PICU, Birmingham Children's Hospital NHS Foundation Trust, Birmingham B4 6NH, UK; adrian.plunkett{at}

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Tell me how you measure me, and I will tell you how I will behave.Eliyahu Moshe Goldratt1

Excellence in healthcare safety

The pursuit of patient safety is a key component of the wider endeavour to improve quality of healthcare delivery. In its contemporary form, safety is characterised as a condition where the occurrence of adverse outcomes is minimised. Our efforts to improve safety are therefore almost entirely focused on identifying adverse incidents and errors, and implementing adaptations to avoid their recurrence. This reactive approach to safety (‘Safety-I’) advocates incident reporting and root-cause analysis in order to identify adverse incidents and their causes.2 Following major reports emphasising the significant role of human error3 and the need for organisational learning from adverse incidents,4 incident reporting has become well established in the National Health Service (NHS). Trends of monitoring and reporting of adverse events are increasing.5 ,6

While this approach may achieve good results, with higher levels of adverse incident reporting correlating with a more positive safety culture,5 some studies of healthcare safety interventions suggest that the benefits of this approach are limited.7 ,8 Adverse incident reporting is widely encouraged in the NHS, but reporting rates and methods for investigating incidents vary widely between organisations. Staff and patients may not always receive feedback about incidents in which they have been involved, and there is often inadequate evidence of lessons learned or effective change implemented following incidents.9

Second victims

An important consideration of Safety-I practice is the potential negative impact on healthcare workers. Staff involved in incidents may often experience the second-victim phenomenon.10 Effects on second victims may include detachment, anxiety and depression, as well as reduced clinical confidence and cognitive functioning, potentially impairing that individual's clinical performance. Some may go on to suffer long-standing issues, similar to …

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