Patient Safety Incident Reporting and Learning Systems: Technical Report and Guidance

This document is to urge the readers to understand the purpose, strengths and limitations of patient safety incident reporting. Data derived from incident reports can be very valuable in understanding the scale and nature of harm arising from health care, provided that the properties of the data are reviewed carefully and conclusions are drawn with caution. The use of incident reporting systems for true learning in order to achieve sustainable reductions in risk and improvements in patient safety is still work in progress. It can be and has been done, but not yet on the scale and with the speed that compares with some other high-risk industries. That is what we must all strive for. This technical guidance will help the journey to a position where we can show patients and their families how we used this learning to give them care that is safe and dependable, every time they need it.