The problem with incident reporting

摘要: ‘The Problem with…’ series covers controversial topics related to efforts improve healthcare quality, including widely recommended, but deceptively difficult strategies for improvement and pervasive problems that seem resist solution. The is overseen by Ken Catchpole (Guest Editor) Kaveh Shojania (Editor-in-Chief). Seminal reports launched the modern field of patient safety highlighted importance learning from critical incidents.1 ,2 Since then, incident reporting systems have become one most widespread in healthcare, both within individual organisations across entire systems.3 There are some strong examples following serious incidents.4 ,5 But major disasters also revealed failures understand respond reported incidents.6 ,7 Between these two extremes exists a range frustrations confusions regarding purpose practice reporting.8–10 These can be traced what was lost translation when adapted aviation other safety-critical industries,11 with fundamental aspects successful misunderstood, misapplied or entirely missed healthcare. This mistranslation industries has left us confused contradictory approaches learning, seriously limiting impact this potentially powerful strategy. The original ambitions were simple. Staff would identify report mishaps; risks investigated addressed resulting lessons shared implemented.12 A symbol ambition ‘orange wire’.13 Successful support system-wide same way discovery defective wire’ particular aircraft type might cause rapid systematic action …