Alex Mendelsohn

A hypothetical proposal for a national incident reporting system in the United States. Drawing on lessons from aviation safety history and patient safety literature, a detailed plan is progressively built (initially centred in psychiatry), covering aspects that make an incident reporting system effective. Incident reporting systems have faced many implementation problems. This article shows that by exploring fields adjacent to medicine and much further afield, solutions to long-standing problems can be found. It proposes potentially novel ideas, yet to have been tried in incident reporting both in the United States and in the UK.

An article about the many mistakes that were made by healthcare staff after a patient's adverse reaction to an antidepressant. This article emphasises that mistakes in healthcare are not only still prevalent, but some can only be picked up through the patient's experience. Most of the healthcare professionals in the story never realised they made a mistake. These mistakes cultivated a loss of trust between patient and healthcare professional, among other negative consequences. The story highlights the importance of the patient perspective in patient safety.

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. 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.