The surprising history of patient safety reporting systems

Summary

This article chronicles the development of patient safety incident reporting systems. From the first implementation by nurses in the 1930s to learn from medication errors, to the accidental revolution in anaesthesiology, and the explosion of reporting systems at the turn of the millennium.

Content

The predominant narrative is that patient safety incident reporting was 'imported' from the aviation industry (and other similar high-risk industries) in the last 25 years. While there is little doubt that other industries have had a major influence on current patient safety incident reporting systems, the narrative ignores the previous 70 years of incident reporting development from within medicine.

The history is important because incident reporting has the potential to be seen as an alien concept to healthcare professionals, when, actually, medicine has historically been independently tied to these systems.

The article emphasises that healthcare practitioners have long seen the value of such systems—and how they are a key part of a learning culture and patient safety.