Establishing a global learning community for incident-reporting systems.
BACKGROUND
Incident-reporting systems (IRS) collect snapshots of hazards, mistakes and system failures occurring in healthcare. These data repositories are a cornerstone of patient safety improvement. Compared with systems in other high-risk industries, healthcare IRS are fragmented and isolated, and have not established best practices for implementation and utilisation.


CONCLUSIONS
Patient safety experts from eight countries convened in 2008 to establish a global community to advance the science of learning from mistakes. This convenience sample of experts all had experience managing large incident-reporting systems. This article offers guidance through a presentation of expert discussions about methods to identify, analyse and prioritise incidents, mitigate hazards and evaluate risk reduction.
Pham
Julius Cuong
JC
The Johns Hopkins University School of Medicine, 1909 Thames Street, 2nd Floor, Baltimore, MD 21231, USA. jpham3@jhmi.edu
Gianci
Sebastiana
S
Battles
James
J
Beard
Paula
P
Clarke
John R
JR
Coates
Hilary
H
Donaldson
Liam
L
Eldridge
Noel
N
Fletcher
Martin
M
Goeschel
Christine A
CA
Heitmiller
Eugenie
E
Hensen
Jörgen
J
Kelley
Edward
E
Loeb
Jerod
J
Runciman
William
W
Sheridan
Susan
S
Wu
Albert W
AW
Pronovost
Peter J
PJ
D004282:Documentation; D006801:Humans; D038622:Internationality; D007858:Learning; D019300:Medical Errors; D011785:Quality Assurance, Health Care / Q000379:methods