Incident Reporting System Research Articles

Family Input for Quality and Safety (FIQS): Using mobile technology for in-hospital reporting from families and patients.

Despite three decades of effort, ensuring inpatient safety remains elusive. Patients and family members are a potential source of safety observations, but systems gathering these are limited. Our goal was to test a system to gather safety observations from hospitalized patients and their family members via a real-time mobile health tool. We developed a mobile-responsive website for reporting safety observations. We piloted the tool during June 2017-April 2018 on the medical-surgical unit of a children's hospital. Participants were English-speaking family members and patients ≥13 years. We sent a daily text with a website link. We assessed: (1) face validity by comparing observations to incident reporting (IR) criteria and to hospital IRs and (2) associations between the number of safety observations/100 patient-days and participant characteristics using Poisson regression. We enrolled 235 patients (43.8% of 537 reviewed for eligibility), resulting in 8.15 safety reports/100 patient-days, most frequently regarding medications (29% of reports) and communication (20% of reports). Fifty-one (40% of 125) met IR criteria; only one (1.1%) had been reported via the IR system. Latinx participants submitted fewer observations than White participants (3.9 vs. 10.1, p = .002); participants with more prior hospitalizations submitted more observations (p < .001). In adjusted analyses, including measures of preference in decision making, and patient activation, the difference between Latinx and White participants diminished substantially (6.4 vs. 11.3, p = .16). We demonstrated the feasibility of real-time patient and family-member technology-enabled safety observation reporting and elicited reports not otherwise identified. Variation in reporting may potentially exacerbate disparities in safety if not addressed.

Extracting Safety-II Factors From an Incident Reporting System by Text Analysis.

IntroductionThe use of electric health records (EHRs) has spread worldwide and has helped record huge amounts of data. However, despite accumulated data from EHRs, especially text data, the information has been underutilized. Our research questions and aims are as follows: How can an incident report system extract common themes behind incidents, good practices, improved quality, and safety based on the Safety-II/resilient healthcare approach?MethodsWe extracted data from the electronic incident reporting system of the Yokohama City University Medical Center between April 1, 2016 and March 31, 2018. We utilized natural language processing and text mining to extract concept categories and word patterns. We also used the incident levels as outcomes, as well as classification and regression tree analysis to obtain associated text combinations.ResultsA total of 17,231 cases were reported through the electronic incident reporting system in our hospital during the study period. Hospital staff has to be prepared for incidents with complex mechanisms in daily practice. The hospital staff tend to focus on individual actions rather than considering a systematic approach.ConclusionCertain combinations of professions and contents may contribute to resilient management. Studies on Safety-II management utilizing clinical information and text records are needed.

Monitoring Preventable Adverse Events and Near Misses: Number and Type Identified Differ Depending on Method Used.

ObjectivesThis study aimed to investigate how many preventable adverse events (PAEs) and near misses are identified through the methods structured record review, Web-based incident reporting (IR), and daily safety briefings, and to distinguish the type of events identified by each method.MethodsOne year of retrospective data from 2017 were collected from one patient cohort in a 422-bed acute care hospital. Preventable adverse events and near misses were collected from the hospital’s existing resources and presented descriptively as number per 1000 patient-days.ResultsThe structured record review identified 19.9 PAEs; the IR system, 3.4 PAEs; and daily safety briefings, 5.4 PAEs per 1000 patient-days. The most common PAEs identified by the record review method were drug-related PAEs, pressure ulcers, and hospital-acquired infections. The most common PAEs identified by the IR system and daily safety briefings were fall injury and pressure ulcers, followed by skin/superficial vessel injuries for the IR system and hospital-acquired infections for the daily safety briefings. Incident reporting and daily safety briefings identified 7.8 and 31.9 near misses per 1000 patient-days, respectively. The most common near misses were related to how care is organized.ConclusionsThe different methods identified different amounts and types of PAEs and near misses. The study supports that health care organizations should adopt multiple methods to get a comprehensive review of the number and type of events occurring in their setting. Daily safety briefings seem to be a particularly suitable method for assessing an organization’s inherent security and may foster a nonpunitive culture.

Learning from an Incident Reporting System: Developing a Strategy to Prevent Medication Errors Among Nursing Students.

Medication errors occur during clinical learning for nursing students. This study aimed to develop learning cases to prevent medication errors using analysis of data from an incident reporting system. This study utilized an action research approach to develop learning cases. These learning cases were implemented with problem-based learning (PBL) method and self-learning materials strategies. The results showed that repeated occurrences of medication errors and near misses were reduced after implementing the new teaching strategy.

Novel Telephone-Based Interactive Voice Response System for Incident Reporting.

The voluntary reporting of medical errors and near misses is a well-established patient safety reporting mechanism. However, studies suggest that these incident reporting systems (IRSs) detect less than 10% of all adverse events. Improving the process of reporting can facilitate more informative and timely data capture while providing more opportunities to improve health care quality and safety. The purpose of this study was to understand the barriers to incident reporting via the existing Web-based IRS and develop solutions to increase the ease and efficiency of reporting. A survey of staff in a diagnostic imaging department in St. Catharines, Ontario was performed to identify barriers to incident reporting. Based on the barriers identified, two methods of incident reporting were tested in successive phases: (1) a phone-based voice message mailbox, in the computed tomography suite; and (2) a phone-based structured interactive voice response system (IVRS), across the entire department. We measured the rate of incident reports/day and time required to complete reports. The three most common barriers to reporting identified were lack of time, complexity of reporting system, and lack of feedback. There was a significant difference in reports per day for the IVRS (mean [M] = 3.43, standard deviation [SD] = 2.71) compared to the IRS (M = 0.99, SD = 0.55); t(31) = 4.58, p ≤ 0.00001. There was also a significant difference in the average time to make a report for the IVRS (M = 97 seconds [s], SD = 30 s) compared to the IRS (M = 644 s, SD = 90 s); t(4) =13.55, p = 0.00025. IVRS is an innovative approach to incident reporting that may prove to be more efficient than Web-based approaches and encourage higher reporting rates.

Thematic and hotspot analysis of human-elk conflicts statewide in California

Human-wildlife conflicts are an important factor for consideration in wildlife management at urban-wildland interfaces. Effective and adaptive management of human-wildlife conflicts is needed to promote tolerance and coexistence of humans and wildlife. Anecdotal reports suggest a recent spike in human-elk conflicts in California, yet there has not been a systematic analysis of human-elk conflicts in the state. To better understand human-elk conflicts in California, we conducted thematic analysis of human-elk conflicts reported in the California Department of Fish and Wildlife’s Wildlife Incident Reporting (WIR) system. We also conducted a hotspot analysis using locations of human-elk conflicts reported in the WIR system and evaluated reports for principles of adaptive management. The WIR system contained n = 89 reports for elk and n = 78 of these described conflicts with elk. Overall, property damage (including crop damage) was the most common type of human-elk conflict reported, occurring in 69% of reports (n = 54/78), followed by non-competitive conflict with domestic animals (13%), competition with domestic livestock (12%), and habituation to humans (24%). We identified three hotspots of human-elk conflict in California in Del Norte, Kern, and San Luis Obispo counties. All incidents of human-elk conflict reported in the WIR system included at least one principle of adaptive management. We recommend modifications to the WIR system and interactions with property owners and stakeholders to enhance and facilitate adaptive management of human-elk conflicts in California.

Seasonality in Air Traffic and Incidence of Dangerous Occurrences in the Polish Air Transport Market in 2010-2017

Purpose: The aim of the research was to identify the relation between flight operations conducted in the summer and winter seasons, and dangerous occurrences which took place then. Design/Methodology/Approach: The research involved the indicator method used in time series analysis. The interdependence between the quantitative variables was determined with the use of the Pearson line correlation coefficient. Statistical data for the analyses was obtained from the European Coordination Centre for Accident and Incident Reporting Systems (ECCAIRS) and the Polish Civil Aviation Authority. Results: Relations were identified between the variables of the number of passengers carried, the number of flight operations conducted, adverse aviation occurrences in 2010-2017, and the winter and summer seasons of the year. The results indicate that these variables are interrelated. Practical implications: The approach employed in analysing the relation between the variables concerned can be applied to processes of pro-active civil aviation safety management. Originality/value: The approach to analysing the variables shown in the paper has not been widely presented in the literature to date.

Medication dose calculation errors and other numeracy mishaps in hospitals: Analysis of the nature and enablers of incident reports.

To investigate medication dose calculation errors and other numeracy mishaps in hospitals and examine mechanisms and enablers which lead to such errors. A retrospective study using descriptive statistics and thematic analysis of the nature and enablers of reported incidents. Medication dose calculation errors and other numeracy mishaps were identified from medication-related incidents reported to the Norwegian Incident Reporting System in 2016 and 2017. The main outcome measures were medications and medication classes involved, severity of harm, outcome, and error enablers. In total, we identified 100 numeracy errors, of which most involved intravenous administration route (n=70). Analgesics were the most commonly reported drug class and morphine was the most common individual medication. Overall, 78 incidents described patient harm. Frequent mechanisms were 10- or 100-fold errors, mixing up units, and incorrect strength/rate entered into infusion pumps. The most frequent error enablers were: double check omitted or deviated (n=40), lack of safety barriers to intercept prescribing errors (n=25), and emergency/stress (n=21). Numeracy errors due to lack of or improper safeguards occurred during all medication management stages. Dose miscalculation after dilution of intravenous solutions, infusion pump programming, and double-checking were identified as unsafe practices. We discuss measures to prevent future calculation and numeracy errors. Our analysis of medication dose calculation errors and other numeracy mishaps demonstrates the need for improving safety steps and increase standardization for medication management procedures. We discuss organizational, technological, and educational measures to prevent harm from numeracy errors.

Comparison of Incidental Thyroid Nodules Between Early Breast Cancer Patients and Healthy Controls: Higher Incidence and Thyroid Imaging Reporting and Data System (TI-RADS) Score of Patients with Cancer

Background: Breast and thyroid cancers remain among the most common malignancies in women. In previous studies, the co-occurrence of thyroid and breast cancers has been reported. Objectives: The aim of this study was to evaluate and compare the risk and incidence of incidental thyroid nodules (ITNs) between patients with breast cancer and healthy controls, based on the Thyroid Imaging Reporting and Data System (TI-RADS). Methods: This case-control study was conducted on 140 patients with breast cancer and 140 cancer-free women in a similar age range. Thyroid ultrasonography (US) was performed before the onset of treatment. The risk stratification of thyroid nodules was based on the TI-RADS. Results: The mean age of the participants was not significantly different between the case (43.35 ± 7.85 years) and control (42.11 ± 3.69 years) groups (P = 0.094). Invasive ductal carcinoma was the most frequent type of breast cancer in the patients. Normal thyroid US findings were significantly less frequent in patients with breast cancer (35.7%) compared to the healthy controls (76.4%) (P = 0.001). On the other hand, thyroid nodules were more frequent in the patients and associated with a higher risk of malignancy (i.e., high TI-RADS scores) compared to healthy women (P = 0.001 and P = 0.001, respectively). Besides, patients with breast cancer showed more thyroid abnormalities in the US examinations. Conclusions: A higher frequency of ITN, with an elevated TI-RADS score, which raised the suspicion of malignancy, was seen in patients with breast cancer. Overall, patients with breast cancer may benefit from a regular thyroid US examination.

Sins of Omission: Are junior doctors failing to report clinical incidents, and if so, how can we better support them to do so?

Objectives University Hospitals Birmingham's (UHB) Foundation Doctors should log clinical incidents via the Trust's incident reporting system. Anecdotal reports suggest under-reporting is commonplace. It is therefore important to identify the proportion of Foundation Year 1 (FY1s) who witnessed but did not report incidents and identify and weigh perceived barriers to reporting. We can then suggest strategies to address these barriers and repeat our data collection. Methodology We performed an analysis of anonymised data from the Trust's Datix Incident Reporting system alongside an anonymised survey to determine the proportion of FY1s witnessing reportable clinical incidents, and the proportion successfully reporting an incident in the 2017/18 academic year. The survey also gathered data on FY1 perceptions of barriers to reporting. We went on to discuss our results with UHB management and suggested several strategies to improve reporting, prior to repeating data collection for the 2019–20 academic year. Results 36.4% FY1 doctors surveyed in 2017–18 reported witnessing at least one clinical incident that they did not report. 37.0% FY1 doctors surveyed in 2019–20 reported the same. Respondents felt time taken to complete forms and system complexity were the key barriers to reporting. Conclusion Results show that over a third of FY1s at UHB had witnessed but not reported at least one clinical incident each year. The evidence-based strategies suggested to the trust in 2018 and 2020 included FY1 education on incident reporting, early senior clinician involvement in the reporting pathway, and a streamlined reporting system integrated with existing infrastructure. These have not been implemented.

Perceived Barriers of Incident Reporting Among Internists: Results from Hamad Medical Corporation in Qatar.

Background Adverse events (AE) are responsible for annual deaths that exceed deaths due to motor vehicle accidents, breast cancer, and AIDS. Many AE are considered preventable. Thus, AE needs to be detected and analyzed. Incident reporting systems (IRS) are crucial in identifying AE. Nevertheless, the incident report (IR) process is flawed with underreporting, especially from the physicians' side. This limits its efficiency in detecting AE. Therefore, we aimed to assess the practice and identify the barriers associated with incident reporting among internal medicine physicians in a large tertiary hospital through a survey. Methods A cross-sectional descriptive study. We distributed an online survey to physicians working in the Internal Medicine Department of Qatar's largest tertiary academic institute. The questionnaire was validated and piloted ahead of the start of the trial. The response rate was 53%. Results A total of 115 physicians completed the survey; 59% acknowledged the availability of an institutional IRS. However, only 29% knew how to submit an online IR, and 20% have ever submitted an IR. The survey revealed that participants were less likely to submit an IR when they or a colleague is involved in the incident; 46% and 63%, respectively. The main barriers of reporting incidents were unawareness about the IRS (36%) and the perception that IR will not bring a system change (13%); moreover, there exists the fear of retaliation (13%). When asked about solutions, 57% recommended training and awareness, and 22% recommended sharing learnings and actions from previous IR. Conclusions IRS is underutilized by internal medicine physicians. The main barrier at the time of the survey is the lack of training and awareness. Promoting awareness and sharing previous learning and actions may improve the utilization of the IRS.

Analyzing the national fire incident reporting system to identify carbon monoxide incidents in the U.S. lodging industry

Carbon Monoxide (CO) poisonings in the U.S. lodging industry have become a regular occurrence, however there is no current mandatory national reporting, tracking, or surveillance mechanism for CO incidents in the U.S. lodging industry. As such, the problem is largely invisible. The objective of this study was to utilize the National Fire Incident Reporting System (NFIRS) data to better understand the public health risk from Carbon Monoxide (CO) incidents in the U.S. lodging industry. The NFIRS datasets for years 1999 through 2018 were assessed to identify CO incidents occurring at U.S. hotels and motels. The results of the analysis identified 3405 incidents. Incidents were strongly correlated with increased fire department participation in NFIRS (R = 0.82). The number and frequency of CO incidents in the U.S. lodging industry are underreported. Previous efforts relying on news media identified only 10% of the incidents reported in the NFIRS data. This indicates a greater public health risk associated with CO exposure in the U.S. lodging industry than previously realized.

Development of incident severity classification for laboratory animals.

An incident reporting system (IRS) prevents possible adverse events by collecting and analyzing incidents that occur. However, few studies are available regarding IRSs in the laboratory animal field. This study aimed to develop an incident severity classification for laboratory animals (ISCLA) to evaluate the usefulness of the IRS in laboratory animal facilities. Twenty-three incidents reported from March 2019 to February 2020 on our IRS were retrospectively reviewed. Three of the 23 incidents failed to obtain some experimental data. Two of these incidents were harmless to animals, but the other caused the animals moderate distress. In addition, two of the three incidents made animals unsuitable for experiments. Since the inconsistent impact of incidents on animals and experiments prevented the comparison of the severity of individual incidents, we developed the ISCLA. According to the ISCLA, the above three incidents were classified into Category 3b and 4a. The others were classified into Category 0 (n=5), 1 (n=6), 2 (n=3), and 3a (n=6) in ascending order of severity. No incident was classified into Category 4b and 5. Furthermore, incidents occurring in the animal housing area were more severe than those occurring in the supporting area (P=0.002). This study showed that incident occurrences had characteristics that were not visible from individual incidents alone. Moreover, the ISCLA was considered useful when conducting the IRS and taking improvement measures in laboratory animal facilities.

Contemporary evaluation of adverse outcome risks associated with 'did not wait' emergency department presentations.

Did not wait (DNW) is a frequently cited ED key performance indicator. We conducted a network-based observational study of consecutive DNW presentations. Prospective cohort study of Western Sydney Local Health District with a primary outcome measure of reported 30-day all-cause mortality and secondary outcomes of demographic characteristics and representation risk. For re-presenting patients who were subsequently admitted, a manual review of electronic records and incident report systems based on a priori plan assessed each case for the length of stay and adverse outcomes. During the study window, there were 1114 DNW presentations with 172 (15.4%) re-presentation within 72 h. The analysis of re-presented patients did not reveal adverse outcomes or prolonged length of stay. A review of available outcomes data revealed one DNW patient died within 30 days but had a previous palliative plan for terminal illness. While a proportion of DNW patients re-presented within 72 h, an excess prevalence of poor outcomes were not observed.

Modifiable risk factors for inpatient violence in psychiatric hospital: prospective study and prediction model.

Violence perpetrated by psychiatric inpatients is associated with modifiable factors. Current structured approaches to assess inpatient violence risk lack predictive validity and linkage to interventions. Adult psychiatric inpatients on forensic and general wards in three psychiatric hospitals were recruited and followed up prospectively for 6 months. Information on modifiable (dynamic) risk factors were collected every 1-4 weeks, and baseline background factors. Data were transferred to a web-based monitoring system (FOxWeb) to calculate a total dynamic risk score. Outcomes were extracted from an incident-reporting system recording aggression and interpersonal violence. The association between total dynamic score and violent incidents was assessed by multilevel logistic regression and compared with dynamic score excluded. We recruited 89 patients and conducted 624 separate assessments (median 5/patient). Mean age was 39 (s.d. 12.5) years with 20% (n = 18) female. Common diagnoses were schizophrenia-spectrum disorders (70%, n = 62) and personality disorders (20%, n = 18). There were 93 violent incidents. Factors contributing to violence risk were a total dynamic score of ⩾1 (OR 3.39, 95% CI 1.25-9.20), 10-year increase in age (OR 0.67, 0.47-0.96), and female sex (OR 2.78, 1.04-7.40). Non-significant associations with schizophrenia-spectrum disorder were found (OR 0.50, 0.20-1.21). In a fixed-effect model using all covariates, AUC was 0.77 (0.72-0.82) and 0.75 (0.70-0.80) when the dynamic score was excluded. In predicting violence risk in individuals with psychiatric disorders, modifiable factors added little incremental value beyond static ones in a psychiatric inpatient setting. Future work should make a clear distinction between risk factors that assist in prediction and those linked to needs.

Incident Reporting System and RCA in A Hospital With Reference To the Standards Laid Down By NABH-A Study

Incident Reporting System and RCA in A Hospital With Reference To the Standards Laid Down By NABH-A Study

Combining spatial and sociodemographic regression techniques to predict residential fire counts at the census tract level

This work examines different spatial and sociodemographic models for predicting residential fire counts at the census tract level for 118 U.S. fire departments across 25 states. The models give five-year forecasts of residential fire counts for 3392 census tracts which contain over 13 million residents in total. All models described in this paper train on fire incident data from the National Fire Incident Reporting System (NFIRS) over the interval 2006–2011 (inclusive) and are evaluated based on their ability to predict the fire counts that occurred over the interval 2012–2016. Two strictly spatial models are considered- a simple “count” model that serves as a baseline for all other models described in the paper and a model that utilizes kernel density estimation (KDE) with statistically optimized bandwidths. Using data from the American Community Survey (ACS), an examination of the effects of demographic and housing factors on the fire risk is presented. The data suggest that the fire risk per person is generally higher in census tracts with attributes corresponding to socioeconomic disadvantage such as low median incomes and small fractions of residents with college degrees. These trends inform the design of a Bayesian hierarchical Poisson regression model, which is shown to make predictions with a 9% lower root mean squared error (RMSE) relative to the base model. A spatial kernel regression is then conducted on the residuals of this regression, which results in a 15% RMSE improvement relative to the base model. These results are compared to a conditional autoregressive (CAR) model, which incorporates spatial information directly into the hierarchical Poisson regression. Although the RMSE is higher for the CAR model's point estimate forecasts (7% lower than the base model), it allows for the generation of probabilistic forecasts and gives spatially-informed statistical estimates of the effects of the sociodemographic variables. This work highlights the utility of geocoded fire incident and demographic data as well as machine learning techniques that can utilize these datasets to make improved predictions.

Proactive flight safety – a feasibility study on optimal use of flight data monitoring and incident reports in an airline

Objectives. This study aimed to identify problems with the use of flight data monitoring (FDM) and incident report systems in an airline, present considerations for improvement and suggest a model of how these considerations relate to increased flight safety and lower costs. Methods. Data were collected from information technology systems and interviews with managers in key positions. The study involved identification and evaluation of available sources of FDM and incident reports, interviews with people in positions with ownership of change, relevant perspectives of safety-related challenges and model creation. Results. Problems include the sheer amount of data collected, floor and ceiling effects, arbitrary cut-off points and lack of interconnectivity with other sources. The incident report system has practical problems (user-interface rigidity, online dependency), unclear responsibility for the overall process and disagreement on what requires follow-up, resulting in fewer reports getting written. Put together, detection of dysfunctional patterns is difficult. Conclusion. Simple proactive interventions using the current data and report systems can ensure higher levels of flight safety and lower costs. This begins with ecologically valid FDM providing a basis for efficient identification and handling of incident reports, which enables learning from malpractices and facilitates communication between management and flying staff.

The Relationship Between Suicidal Behaviors and Zero Suicide Organizational Best Practices in Outpatient Mental Health Clinics.

This study tested the hypothesis that fidelity of clinics to Zero Suicide (ZS) organizational practices is inversely related to suicidal behaviors of patients under clinical care. Using cross-sectional analyses, the authors examined the fidelity of 110 outpatient mental health clinics to ZS organizational best practices and suicidal behaviors of clinic patients in the year before a large-scale Zero Suicide implementation. Fidelity to ZS organizational best practices was assessed over a 1-year period with an adapted version of the ZS Organizational Self-Study instrument (17 items self-rated on a Likert scale of 1-5). Suicidal behaviors of patients were identified by extracting information on suicide attempts and deaths from a mandated statewide incident-reporting system database. Clinics were dichotomized into any or no suicide incidents during the year of observation. Logistic regression analyses were used to adjust for clinic census and population type (majority child or adult). The clinics (N=110) served 30,257 patients per week. Clinics' total average fidelity score was 3.1±0.6 (range=1.41-4.12). For each point increase in fidelity, clinics had a significantly reduced likelihood of having a suicide incident (adjusted odds ratio=0.31, 95% confidence interval=0.14-0.69). Exploratory analysis identified significant differences for seven of 17 ZS organizational practices, with the largest effect sizes for suicide-specific quality improvement policies and activities (η2=0.097) and lethal means reduction (η2=0.073). These findings support an association between clinics' use of ZS organizational best practices and lower suicidal behaviors of patients under their care. Findings also support the validity of the ZS Organizational Self-Study instrument.

Learning from safety incidents in high-reliability organizations: a systematic review of learning tools that could be adapted and used in healthcare.

ObjectiveA high-reliability organization (HRO) is an organization that has sustained almost error-free performance, despite operating in hazardous conditions where the consequences of errors could be catastrophic. A number of tools and initiatives have been used within HROs to learn from safety incidents, some of which have the potential to be adapted and used in healthcare. We conducted a systematic review to identify any learning tools deemed to be effective that could be adapted and used by multidisciplinary teams in healthcare following a patient safety incident.MethodsThis review followed the Preferred Reporting Items for Systematic Reviews and MetaAnalyses for Protocols reporting guidelines and was registered with the PROSPERO (CRD42017071528). A search of databases was carried out in January 2021, from the date of their commencement. We conducted a search on electronic databases such as Web of Science, Science Direct, MEDLINE in Process Jan 1950-present, EMBASE Jan 1974-present, CINAHL 1982-present, PsycINFO 1967-present, Scopus and Google Scholar. We also searched the grey literature including reports from government agencies, relevant doctoral dissertations and conference proceedings. A customized data extraction form was used to capture pertinent information from included studies and Critical Appraisal Skills Programme tool to appraise on their quality.ResultsA total of 5921 articles were identified, with 964 duplicate articles removed and 4932 excluded at the title (4055), abstract (510) and full-text (367) stages. Twenty-five articles were included in the review. Learning tools identified included debriefing, simulation, crew resource management and reporting systems to disseminate safety messages. Debriefing involved deconstructing incidents using reflective questions, whilst simulation training involved asking staff to relive the event again by performing the task(s) in a role-play scenario. Crew resource management is a set of training procedures that focus on communication, leadership and decision-making. Sophisticated incident-reporting systems provide valuable information on hazards and were widely recommended as a way of disseminating key safety messages following safety incidents. These learning tools were found to have a positive impact on learning if conducted soon after the incident with efficient facilitation.ConclusionHealthcare organizations should find ways to adapt to the learning tools or initiatives used in HROs following safety incidents. It is challenging to recommend any specific one as all learning tools have shown considerable promise. However, the way these tools or initiatives are implemented is critical, and so further work is needed to explore how to successfully embed them into healthcare organizations so that everyone at every level of the organization embraces them.