Learning from incidents in healthcare: the journey, not the arrival, matters

Leistikow, Ian; Mulder, S.; Vesseur, Jan; Robben, Paul

doi:10.1136/bmjqs-2015-004853

Cited by 90 publications

(112 citation statements)

References 13 publications

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“…Incident reporting systems alone are not a valid, patient safety strategy (Leistikow, Mulder, Vesseur, & Robben, ). Reason's famous “Swiss cheese model” is now out‐dated (Reason, Hollnagel, & Paries, ) and Hollnagel et al.…”

Section: Resultsmentioning

confidence: 99%

“…Incident reporting systems alone are not a valid, patient safety strategy (Leistikow, Mulder, Vesseur, & Robben, 2016). Reason's famous "Swiss cheese model" is now out-dated (Reason, Hollnagel, & Paries, 2006) and Hollnagel et al (2015) propose learning from RCA is obsolete in complex environments where people and technology interact.…”

Section: Safety Surveillancementioning

confidence: 99%

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Surveillance, anticipation and firefighting: Perspectives of patient safety from a New Zealand case study

2019

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Aim This study explored how doctors, nurses and managers working in a New Zealand tertiary hospital understand patient safety. Background Despite health care systems implementing proven safety strategies from high reliability organisations, such as aviation and nuclear power, these have not been uniformly adopted by health care professionals with concerns raised about clinician engagement. Design Instrumental, embedded case study design using qualitative methods. Methods The study used purposeful sampling, and data was collected using focus groups and semi‐structured interviews with doctors (n = 31); registered nurses (n = 19); and senior organisational managers (n = 3) in a New Zealand tertiary hospital. Results Safety was described as a core organisational value. Clinicians appreciated proactive safety approaches characterized by anticipation and vigilance, where they expertly recognized and adapted to safety risks. Managers trusted evidence‐based safety rules and approaches that recorded, categorized and measured safety. Conclusion and Implications for Nursing Management It is important that nurse managers hold a more refined understanding about safety. Organisations are more likely to support safe patient care if cultural complexity is accounted for. Recognizing how different occupational groups perceive and respond to safety, rather than attempting to reinforce a uniform set of safety actions and responsibilities, is likely to bring together a shared understanding of safety, build trust and nurture safety culture.

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Section: Resultsmentioning

confidence: 99%

Section: Safety Surveillancementioning

confidence: 99%

Surveillance, anticipation and firefighting: Perspectives of patient safety from a New Zealand case study

2019

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“…These challenges do not mean that RCA is never worthwhile; it certainly can be a source of important learning73 and improvement 74. But it does mean that we cannot afford to compound these problems through the use of an RCA tool that is so deeply and fundamentally flawed.…”

Section: Considering the Virtues Of ‘5 Whys’mentioning

confidence: 99%

The problem with ‘5 whys’

Card¹

2016

BMJ Qual Saf

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“…Patient safety and quality improvement are rapidly evolving disciplines in human medicine involved the reduction of harm directly caused to patients by the healthcare they are receiving. The voluntary reporting and analysis of safety incidents are considered as key elements of these disciplines [1] [2]. Incident reports can be viewed as a "window on the system" in which they provide valuable insights into gaps and inadequacies in healthcare provisions [3].…”

Section: Introductionmentioning

confidence: 99%

Evaluation and Outcomes of Multidisciplinary-Reported Incidents Regarding Patient Safety Management at Special Functioning Hospital in Japan

Ayabe¹,

Tomita²,

Okumura³

et al. 2018

OJSST

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Background: It is an important study to investigate incident reports submitted by multidisciplinaries in the Special Functioning Hospitals of Japan. We clarify the characteristics of the incidents and evaluate the outcomes obtained from a polygonal analysis. Material and Methods: We collected 1638 incident reports submitted by multidisciplinaries for one year from April, 2016 to March, 2017. The incidents were retrospectively analyzed by profile, levels, distribution, and ratios. Results: The majority of incidents (94.7%, 1551/1638) were distributed between the levels 0 to 3a, on the other hand, the incidents of a level higher than 3b occupied 5.3%. The reports from nurses were 75.3% (1234/1638) and those from doctors were 12.8% (209/1638). The level 3b totalled 30.6% (64/209) of the doctor-reported incidents. In contrast, the level 2 totalled 33.8% (417/1234) of the nurse-reported incidents. The levels of the doctor-incidents were comparatively higher than those of the nurse-incidents. The profiles of the incidents were categorized as drug administration (n = 439, 26.8%), nursing care (n = 399, 24.4%), drain and tube (n = 258, 15.8%), medical treatment and care (n = 199, 12.1%), medical examination (n = 141, 8.6%), medical equipment (n = 99, 6.0%), giving instructions (n = 66, 4.0%) and blood transfusion (n = 12, 0.7%). Conclusions: It is important for multidisciplinaries to report incidents because they can learn novel experiences from the incidents for preventing a recurrence. By proper utilizing of the incident-reporting system, it could be an effective tool that helps the medical staff build a strong patient safety culture,

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Learning from incidents in healthcare: the journey, not the arrival, matters

Cited by 90 publications

References 13 publications

Surveillance, anticipation and firefighting: Perspectives of patient safety from a New Zealand case study

Surveillance, anticipation and firefighting: Perspectives of patient safety from a New Zealand case study

The problem with ‘5 whys’

Evaluation and Outcomes of Multidisciplinary-Reported Incidents Regarding Patient Safety Management at Special Functioning Hospital in Japan

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