ABSTRACT
There have been signicant advances in health care over the last decade, and patients now receive treatments that were unlikely in the past. However, these signicant strides in therapeutic developments have not been matched by a corresponding reduction in iatrogenic harm. Some positive steps have been made: for example, patient safety has gained global importance and is a key program of the World Health
Key Points .............................................................................................................. 157 Introduction ............................................................................................................ 157 Approaches to Conceptualizing, Populating, and Interrogating Data .................... 159 The National Reporting and Learning System for England and Wales ................. 162
Origins ............................................................................................................... 162 Structure ............................................................................................................ 162 Approaches to Data Generation and Analysis ................................................... 162 Developing Alerts .............................................................................................. 163
Pre-2011 ....................................................................................................... 165 2012 Onwards ............................................................................................... 165
Strengths and Limitations of Incident Reporting Systems .................................... 167 Comprehensiveness ........................................................................................... 167 Quality ............................................................................................................... 168
Conclusion ............................................................................................................. 169 Commentary ........................................................................................................... 169
Organization (WHO) (World Health Organization 2002). This chapter described the rationale and approaches to using incident reporting systems as learning tools to provide feedback to organizations to mitigate the risk of error. Feedback to individuals is covered elsewhere in Chapter 18. At the end of this chapter, there is an expert commentary about the potential value of applying this approach internationally.
