The problem with incident reporting by Carl Macrae (7 September 2015)

Summary

In the past 15 years, healthcare has focused primarily on building the technical infrastructure for incident reporting systems: online reporting systems, data collection forms, categorisation schemes and analytical tools. These are all important foundations. But this focus on incident data is also the source of many of our current problems with incident reporting: we collect too much and do too little. Learning depends critically on the less visible social processes of inquiry, investigation and improvement that unfold around incidents. Over the next 15 years we must refocus our efforts and develop more sophisticated infrastructures for investigation, learning and sharing, to ensure that safety incidents are routinely transformed into system wide improvements.