Improving the health system’s response when patients are harmed: a mixed-methods study

Health systems use incident management systems (IMS) to collect incidents when patients are harmed, e.g., due to errors in medication or surgical complications. I'm involved in reporting and analysing incidents, investigating serious incidents, and taking action in response. There is a strong ethical case for IMSs – when patients are harmed, it is imperative that healthcare organisations respond to and learn from them and attempt to prevent other patients from suffering a similar incident. However, internationally, there is a lack of understanding of how incidents should be optimally reviewed or managed and there is no evidence that IMSs and associated investigations are effective in reducing the frequency of incidents causing harm to patients. Furthermore, IMSs consume large resources, particularly the time of senior clinicians, managers, executives, Boards, and Ministers of Health. In partnership with 4 jurisdiction health departments and the national governing body in patient safety, we will develop and test evidence-based methods for healthcare organisations to improve and measure their response, analysis and learning from incidents, thereby reducing harm to patients. There are 3 arms to the research: we will learn from current practices and innovations – natural experiments occurring in 31 health services using a mixed-methods design and an implementation science framework (the Consolidated Framework for Implementation
Research) to guide the research; undertake a world-first innovative simulation trial using artificial intelligence (AI); and an Australian-first costing of incident management. We have embedded a phase to share lessons from the research nationally and internationally. This is an important phase as our research will be highly applicable and transferable to other Australian states and internationally as health services have similar overarching models of IMSs.