In this resource :

  • Patient Safety and Incident Management Toolkit

Reporting and Learning Systems 

Reporting systems (frequently referred to as reporting and learning systems) capture patient safety concerns, hazards and/or incidents and are meant to trigger action, facilitate communication, response, learning and improvement. Establishing a reporting system and processes to support it, including identifying and spreading learning, is foundational to patient safety and incident management and essential to advancing a patient safety culture. 

“To close the safety gaps in my hospital, first I need to know where they are. Reporting systems serve as a map to show us where the gaps are and guide us in how to close them.” -- Toolkit Faculty 

Recommended strategies 

Establish a reporting system. 

  • Capture information about hazards, patient safety concerns, incidents and near misses, typically by completing a standardized electronic or paper form 
  • Consider establishing alternate reporting mechanisms such as telephone or verbal, particularly for incidents with a high potential for harm to ensure timely response (e.g. stop the line) 
  • Compared to those that are mandatory, voluntary (non-legislated) reporting systems have been shown to facilitate greater reporting and learning 
  • Empower and support reporting by all care participants, including the patient/family, by ensuring they can access the system 
  • Engage the users, including patients/families, in developing and maintaining the system 
  • Incorporate best practices into the design of the reporting system whenever possible: 
    • make the system user-friendly aligning with human factors design principles 
    • limit the information required to what is essential and include a narrative portion to allow reporters to tell the story 
    • provide an option for anonymous or confidential reporting to address concerns about potential negative consequences 
    • embed automatic notification of the appropriate department head or manager, eliminating the need for the reporter to determine where to direct the information 
    • acknowledge reports upon receipt conveying appreciation to the individual submitting the report 
    • develop process(es) for the reporter to clarify the information submitted, if required 
    • enable managers to receive and view reports in real-time to facilitate timely feedback and response 
    • facilitate the review of the reports completed by the patient/family in conjunction with those completed by care providers 
    • prompt users to consider external reporting or notification requirements when appropriate (e.g. National System for Incident Reporting, Canadian Medication Incident Reporting and Prevention System) 
    • create easy-to-use data extraction capability to support timely improvement at the local, organizational and system-wide levels 
    • ensure appropriate data confidentiality and security (including de-identification), in accordance with applicable legislation and organizational policies 

Establish processes that support reporting systems. 

  • Develop and/or review existing reporting policies, procedures, education and training (example of policy and guideline from AHS) to ensure users know what, how and when to report: 
    • emphasize that reporting is a positive action that contributes to patient safety, and neither the person who reports nor those involved in or caused the event will be reprimanded 
    • develop tools and resources specifically for patients/families 
    • ensure roles and accountabilities around incident reporting are clearly delineated and that staff is familiar with reporting procedures and tools 
    • clearly communicate what happens to the information once it is entered into the reporting system 
  • Integrate reporting processes and the responsibility for reporting within existing work processes, structures and accountabilities including role descriptions, staff orientation and leadership development programs 
  • Allocate adequate resources (including technical and administrative) to maintain the reporting system and its related processes including data analysis, follow-up, and system oversight 
  • Address potential organizational barriers to reporting: 
    • cultivate a patient safety culture, specifically addressing the potential fears associated with reporting, authority gradient, and the risk of reprisal 
    • develop and train leaders to promote openness, facilitate learning, empower teams, and welcome differing perspectives 

Optimize and share learning from reporting systems. 

  • Analyze data from the reporting system to identify patient safety gaps 
  • Integrate reporting system information with other data sources to anticipate  and mitigate clinical risk and system vulnerabilities as well as to identify system strengths 
  • Provide updates on lessons learned and improvements made as a result of reporting as part of routine processes, e.g. regular agenda item at staff and board meetings, “good catch” stories in newsletters, summaries at town hall meetings 
  • Consider sharing lessons learned with patients, families, communities, public and tailor communication to the needs of the specific audience, e.g. quantitative analyses, patient stories, trend summaries, poster campaigns, social media, blogs 
  • Evaluate the effectiveness of the reporting system and its related feedback mechanisms on a regular basis and make improvements 
  • Update the data elements collected to ensure relevance and incorporate identification of emerging issues