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International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process

Research output: Contribution to journalArticlepeer-review

Ann-Marie Howell, Elaine M Burns, Louise Hull, Erik Mayer, Nick Sevdalis, Ara Darzi

Original languageEnglish
JournalBMJ Quality and Safety
Early online date22 Feb 2016
Accepted/In press24 Jan 2016
E-pub ahead of print22 Feb 2016


  • Howell_et_al_2016_BMJ_QS_Reporting_Guidelines

    Howell_et_al_2016_BMJ_QS_Reporting_Guidelines.docx, 208 KB, application/vnd.openxmlformats-officedocument.wordprocessingml.document

    Uploaded date:07 Mar 2016

    Version:Accepted author manuscript

King's Authors


BACKGROUND: Patient safety incident reporting systems (PSRS) have been established for over a decade, but uncertainty remains regarding the role that they can and ought to play in quantifying healthcare-related harm and improving care.

OBJECTIVE: To establish international, expert consensus on the purpose of PSRS regarding monitoring and learning from incidents and developing recommendations for their future role.

METHODS: After a scoping review of the literature, semi-structured interviews with experts in PSRS were conducted. Based on these findings, a survey-based questionnaire was developed and subsequently completed by a larger expert panel. Using a Delphi approach, consensus was reached regarding the ideal role of PSRSs. Recommendations for best practice were devised.

RESULTS: Forty recommendations emerged from the Delphi procedure on the role and use of PSRS. Experts agreed reporting system should not be used as an epidemiological tool to monitor the rate of harm over time or to appraise the relative safety of hospitals. They agreed reporting is a valuable mechanism for identifying organisational safety needs. The benefit of a national system was clear with respect to medication error, device failures, hospital-acquired infections and never events as these problems often require solutions at a national level. Experts recommended training for senior healthcare professionals in incident investigation. Consensus recommendation was for hospitals to take responsibility for creating safety solutions locally that could be shared nationally.

CONCLUSIONS: We obtained reasonable consensus among experts on aims and specifications of PSRS. This information can be used to reflect on existing and future PSRS, and their role within the wider patient safety landscape. The role of PSRS as instruments for learning needs to be elaborated and developed further internationally.

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