Healthcare With Numerous Advantages And Disadvantages Assignment

Incident reporting is a valuable learning tool in healthcare, with numerous advantages and disadvantages. It can improve safety and enhance learning from incidents and near misses, which are more frequently occurring due to the lack of documentation in medical records. Implementing an incident reporting system is more cost-effective and can detect more preventable adverse events than a medical record review. However, barriers such as lack of education or cultural issues like fear of punishment, legal ramifications, and discrimination in the workplace can hinder the use of incident reporting data.

Incident reporting data with the acute NHS system appears to be used as storage for information, instead of being used for insight and learning occurrences. Data mining software is still immature in healthcare, and when used effectively, data extraction could have huge potential to improve safety and quality of care, such as linking occurrences between patient data.

Goldman (2010) describes his initial response of single loop learning and later evolved into a double and triple loop learning curve. Mahajan (2010) adopts a system thinking approach, analysing data to examine how each process affects the entire healthcare system. Design thinking is also used to examine how human factors interlink with each other and how they could be overcome.

Incident reporting data can be used as a learning tool by normalizing mistakes and human error in medicine, reducing shame, supporting clinicians through their learning experience, and identifying areas of concern such as the timing of incidents. A standardized framework can increase engagement from clinicians and ensure all incidents are investigated with the same level of integrity, giving staff the confidence that reports are acknowledged and actioned fairly and non-punitive.

Mahajan (2010) suggests a hierarchy method for investigating patients and staff performance within their team factors and working conditions under organizational and institutional factors. This method provides a system-based thinking approach to incidents by analyzing how each level interacts with others. Data mining can identify trends that other frameworks might not detect, such as falls, ulcers, and treatment errors. One strength of data mining is that "unknown unknowns" can transition to "known knowns."

One weakness noted across all the materials provided is the quality of data entered into the incident reporting system, which directly affects the quality of analysis and feedback. Good quality data entry comes from engaged clinicians who see merit in reporting incidents they experience. Disengaged clinicians can be a result of misunderstanding what qualifies as a reportable incident, and clinicians may not understand the importance of near misses or incidents without harm as valuable learning opportunities.

SA Health's Safety Learning System (SLS) is a reporting system that records incidents involving patients and staff. Reports created based on SLS data show that the team investigates and closes incidents on average within 10 days. The South Australian Patient Safety Report is generated by SA Health on SLS data, demonstrating SA Health's commitment to a strong organizational safety culture.

Mahajan (2020) emphasizes the importance of keeping clinicians "in the loop" to provide feedback and ensure feedback is not received negatively by those involved in the incident. Building psychological safety within a team is vital for creating a learning safety culture. Goldman's TED Talk (2010) confirms this approach.

However, the translation of this information at a local level is important, as many local health networks have an 'Incident Review Panel' or a 'Morbidity and Mortality' committee to review such incidents. To create a safe space for improved incident reporting, it is essential to see the quality improvement work being done connected to the incidents being reported. Involving staff who were initially involved in the error and being creative in coming up with suggestions on improving systems and processes can help build reflection into daily practice.

In conclusion, Mahajan's hierarchy method provides a system-based thinking approach to incident reporting, highlighting the importance of engaging clinicians and fostering a learning safety culture.

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