TY - JOUR
T1 - Patient safety's missing link
T2 - using clinical expertise to recognize, respond to and reduce risks at a population level
AU - Hibbert, Peter D.
AU - Healey, Frances
AU - Lamont, Tara
AU - Marela, William M.
AU - Warner, Bruce
AU - Runciman, William B.
PY - 2016/2
Y1 - 2016/2
N2 - Introduction: 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.
Requirements for a population-level response: 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.
Discussion: 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.
AB - Introduction: 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.
Requirements for a population-level response: 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.
Discussion: 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.
KW - incident reporting and analysis
KW - patient safety
KW - risk management
KW - medical errors
KW - human factors
KW - adverse events
KW - Incident reporting and analysis
UR - http://purl.org/au-research/grants/nhmrc/1054146
UR - http://www.scopus.com/inward/record.url?scp=84960112238&partnerID=8YFLogxK
U2 - 10.1093/intqhc/mzv091
DO - 10.1093/intqhc/mzv091
M3 - Article
C2 - 26573789
SN - 1353-4505
VL - 28
SP - 114
EP - 121
JO - International Journal for Quality in Health Care
JF - International Journal for Quality in Health Care
IS - 1
ER -