title: Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level.
abstract: BACKGROUND
  Although incident reporting systems are widespread in health care as a strategy to reduce harm to patients, the focus has been on reporting incidents rather than responding to them. Systems containing large numbers of incidents are uniquely placed to raise awareness of, and then characterize and respond to infrequent, but significant risks. The aim of this paper is to outline a framework for the surveillance of such risks, their systematic analysis, and for the development and dissemination of population-based preventive and corrective strategies using clinical and human factors expertise.
  The framework outlines four system requirements: to report incidents; to aggregate them; to support and conduct a risk surveillance, review and response process; and to disseminate recommendations. Personnel requirements include a non-hierarchical multidisciplinary team comprising clinicians and subject-matter and human factors experts to provide interpretation and high-level judgement from a range of perspectives. The risk surveillance, review and response process includes searching of large incident and other databases for how and why things have gone wrong, narrative analysis by clinical experts, consultation with the health care sector, and development and pilot testing of corrective strategies. Criteria for deciding which incidents require a population-level response are outlined.
  
  
  CONCLUSIONS
  The incremental cost of a population-based response function is modest compared with the 'reporting' element. Combining clinical and human factors expertise and a systematic approach underpins the creation of credible risk identification processes and the development of preventive and corrective strategies.
authors.affiliation: Australian Institute of Health Innovation, Macquarie University, Sydney, Australia Visiting Research Fellow, Centre for Population Health Research, School of Health Sciences, University of South Australia, Adelaide, Australia.
authors.forename: Peter D
authors.initials: PD
authors.lastname: Hibbert
authors.affiliation: Head of Patient Safety Insight, NHS England, London, UK.
authors.forename: Frances
authors.initials: F
authors.lastname: Healey
authors.affiliation: National Institute for Health Research, London, UK Health Services and Delivery Research Programme, University of Southampton, Southampton, UK.
authors.forename: Tara
authors.initials: T
authors.lastname: Lamont
authors.affiliation: Pennsylvania Patient Safety Authority, Harrisburg, PA, USA.
authors.forename: William M
authors.initials: WM
authors.lastname: Marela
authors.affiliation: Deputy Chief Pharmaceutical Officer, NHS England, London, UK.
authors.forename: Bruce
authors.initials: B
authors.lastname: Warner
authors.affiliation: Australian Institute of Health Innovation, Macquarie University, Sydney, Australia Centre for Population Health Research, School of Health Sciences, University of South Australia, Adelaide, South Australia Joanna Briggs Institute, Faculty of Health Sciences, University of Adelaide, Adelaide, Australia.
authors.forename: William B
authors.initials: WB
authors.lastname: Runciman
mesh_terms: D006801:Humans; D019300:Medical Errors / Q000517:prevention & control*; D061214:Patient Safety; D011785:Quality Assurance, Health Care; D018570:Risk Assessment / Q000379:methods*
keywords: adverse events; human factors; incident reporting and analysis; medical errors; patient safety; risk management