Use Of Incident Reporting System Research Articles

Psychological Safety and Use of Incident Reporting Systems

Psychological Safety and Use of Incident Reporting Systems

ISQUA16-1828EVALUATION FRAMEWORK FOR PATIENT SAFETY INCIDENT REPORTING SYSTEMS:

Research Question: What are the indicators of a successful patient safety incident reporting (IR) system, and what framework can be applied to ensure IR systems are evaluated comprehensively? Patient safety IR systems operate widely across health systems as mechanisms to improve accountability, facilitate learning and promote a culture of patient safety. Despite the widespread use of IR systems, there is no standard evaluation framework to measure and monitor them to ensure they are achieving their intended goals. Collate evidence on what makes a successful …

Preventing black swans: incident reporting systems as collective knowledge management

In hazardous industries, disasters are mercifully rare and yet the potential is ever present. For this reason, companies and industries as a whole put substantial effort into gathering information about past small failures and their causes in an attempt to learn how to prevent more serious events. Despite these efforts, recent research has captured how organizations can ‘fail’ to learn. Disastrous events can become ‘black swans’ and remain unpredicted despite the existence of information warning of them. This article engages with this challenge by analyzing incident-reporting systems as a tool for collective knowledge. Drawing together the literatures on organizational knowledge management and incident reporting, we examine incident-reporting systems as used and as structured. We explore the potential use of incident-reporting systems for mediation and synchronization of knowledge within and across groups of professionals and organizations. We also address the social practices that translate information in databases into collective knowledge. Building on the work of Hecker, we argue that research concerned with incident reporting and organizational learning would benefit from using ‘knowledge’ and specifically ‘collective knowledge’ as its reference point. We show that conceptualizing this problem in terms of ‘reporting’ and ‘learning’ distracts attention from the knowledge needs for people to learn. We argue that we must ask: What do people need to know to play their part in major accident prevention? And how is that knowledge effectively shared? We conclude with an empirical research agenda in light of this investigation.

The frustrating case of incident-reporting systems

Even for those interested in patient safety and quality improvement, incident-reporting (IR) systems often represent a source of frustration, rather than a useful tool for capturing important patient-safety and quality-of-care...