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PSNet: Patient Safety Network
Journal Article

Learning from incident reporting? Analysis of incidents resulting in patient injuries in a web-based system in Swedish health care.

Ahlberg E-L, Elfström J, Borgstedt MR, et al. J Patient Saf. 2020;16(4):264-268.

Incident reporting systems and root cause analyses are the primary mechanisms by which adverse events are identified and reviewed. This analysis of incident reports occurring at one hospital in Sweden found that the handling, causes, and actions taken to prevent recurrence of injuries were similar across three severity levels (injuries leading to deaths, permanent harm, or temporary harm). However, the feedback generated based on these reports was primarily used at the department level and did not lead to organizational learning.