Without an atmosphere where the workers feel confident to report the incidents and adverse events it is not possible to learn from the failures and to improve patient safety. To achieve this positive environment, it’s necessary a leaderships commitment and to take practical measures towards it, as education and training on Patient Safety.
But there are more difficulties to put in practice an effective learning system: the effort on collecting data creates a massive volume of information to examine, whereas the investment on analysing is many times proportionally small. The poor specification of what is to be reported and the data incompleteness are also, among others, weaknesses shown by previous studies. 1
The healthcare workers could feel personally discouraged to report incidents due to lack of time and lack of feedback from previous reports.
The WHO launched the Patient Safety Incident Reporting and Learning Systems – Technical report and guidance1 to support the establishment or reinforce the reporting mechanisms and to maximize the performance of learning from incidents. The document has also a self-assessment questionnaire that could be used by the organisations to evaluate their report system and to promote further discussion about strengths and improvements to take.
1. World Health Organization. Patient Safety Incident Reporting and Learning Systems: technical report and guidance. Geneva: World Health Organization; 2020