Seeking systems-based facilitators of safety and healthcare resilience: a thematic review of incident reports

• Published in: International journal for quality in health care Vol. 36; no. 3
• Main Authors: Leon, Catherine, Hogan, Helen, Jani, Yogini H
• Format: Journal Article
• Language: English
• Published: UK Oxford University Press 09.07.2024
• Subjects: Original; risk management; patient safety; medication safety; incident reporting; governance; Patient Safety Medication safety Risk Management Governance Incident reporting
• ISSN: 1353-4505; 1464-3677; 1464-3677
• DOI: 10.1093/intqhc/mzae057

Abstract Patient safety incident reports are a key source of safety intelligence. This study aimed to explore whether information contained in such reports can elicit facilitators of safety, including responding, anticipating, monitoring, learning, and other mechanisms by which safety is maintained. The review further explored whether, if found, this information could be used to inform safety interventions. Anonymized incident reports submitted between August and October 2020 were obtained from two large teaching hospitals. The Systems Engineering Initiative for Patient Safety (SEIPS) tool and the resilience potentials (responding, anticipating, monitoring, and learning) frameworks guided thematic analysis. SEIPS was used to explore the components of people, tools, tasks, and environments, as well as the interactions between them, which contribute to safety. The resilience potentials provided insight into healthcare resilience at individual, team, and organizational levels. Sixty incident reports were analysed. These included descriptions of all the SEIPS framework components. People used tools such as electronic prescribing systems to perform tasks within different healthcare environments that facilitated safety. All four resilient capacities were identified, with mostly individuals and teams responding to events; however, monitoring, anticipation, and learning were described for individuals, teams, and organizations. Incident reports contain information about safety practices, much of which is not identified by traditional approaches such as root cause analysis. This information can be used to enhance safety enablers and encourage greater proactive anticipation and system-level learning.