Assessing the quality of patient safety incident investigation reports (8 July 2026)

Summary

This study aimed to assess the quality of a sample of Australian patient safety incident investigation reports, looking at 300 reports from 56 Australian health services. It found that a detailed and complete description of events was present in just over half of the reports (57%). There was also variable application of systems approaches to incident causation in the reports. Generally, there was evidence that the people affected were engaged with, and the avoidance of blame and counterfactual reasoning was well executed, as was overall writing quality.

The authors highlight several areas in need of improvement, including identifying contributing factors beyond the staff and local hospital, the use of appropriate scientific literature and using observational insights to enhance understanding of work-as-done, their sample only 4% used observation techniques to examine healthcare processes.