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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Both Saskatchewan and Manitoba have embarked on major provincial quality improvement endeavours that include a mandatory reporting and learning process aimed at enhancing patient safety by reducing the potential for recurrence of critical incidents. This move from a voluntary, less comprehensive process signals a commitment from policy makers that substantial improvements to safety will occur only when adverse events are addressed systemically within the healthcare system. Saskatchewan took the lead with the passage of legislative requirements to report, investigate and share learnings arising from critical incidents as of September 15, 2004. Manitoba is due to implement similar requirements in 2006. The focus of legislation in both provinces is aimed at reporting for learning in order to strive for further improvements in patient safety. By empowering staff and physicians to actively participate in risk identification and mitigation, both provinces have become leaders in patient safety. Saskatchewan and Manitoba have taken an innovative and collaborative approach to strive for substantive system changes, seeking out best practices in the areas of quality and patient safety.

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