Analysis of clinical incidents: a window on the system not a search for root causes

Incident reporting lies at the heart of many initiatives to improve patient safety. The UK National Patient Safety Agency (NPSA)1 has recently launched a national reporting and learning system following substantial piloting and testing across the National Health Service (NHS). In the USA the Agency for Healthcare Research and Quality (AHRQ) made incident reporting the centrepiece of its first patient safety funding programme, investing $25 million in the first year into research in incident reporting systems.2 The Australian incident monitoring system has amassed a massive database of reports over 15 years.3 New risk management and patient safety programmes—whether local or national—rely on incident reporting to provide data on the nature of safety problems and to provide indications of the causes of those problems and the likely solutions.

Incident reports by themselves, however, tell you comparatively little about causes and prevention, a fact which has long been understood in aviation.4 Reports are often brief and fragmented; they are not easily classified or pigeon holed. Making sense of them requires clinical expertise and a good understanding of the task, the context, and the many factors that may contribute to an adverse outcome. At a local level, review of records and, above all, discussions with those involved can lead to a deeper understanding of the causes of an incident. Surprisingly little attention, however—and even less …