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Type: Journal article
Title: Patient safety's missing link: using clinical expertise to recognize, respond to and reduce risks at a population level
Author: Hibbert, P.
Healey, F.
Lamont, T.
Marela, W.
Warner, B.
Runciman, W.
Citation: International Journal for Quality in Health Care, 2016; 28(1):114-121
Publisher: Oxford University Press
Issue Date: 2016
ISSN: 1353-4505
Statement of
Peter D. Hibbert, Frances Healey, Tara Lamont, William M. Marela, Bruce Warner and William B. Runciman
Abstract: Introduction: Although incident reporting systems are widespread in health care as a strategy to reduce harm to patients, the focus has been on reporting incidents rather than responding to them. Systems containing large numbers of incidents are uniquely placed to raise awareness of, and then characterize and respond to infrequent, but significant risks. The aim of this paper is to outline a framework for the surveillance of such risks, their systematic analysis, and for the development and dissemination of population-based preventive and corrective strategies using clinical and human factors expertise. Requirements for a population-level response: The framework outlines four system requirements: to report incidents; to aggregate them; to support and conduct a risk surveillance, review and response process; and to disseminate recommendations. Personnel requirements include a non-hierarchical multidisciplinary team comprising clinicians and subject-matter and human factors experts to provide interpretation and high-level judgement from a range of perspectives. The risk surveillance, review and response process includes searching of large incident and other databases for how and why things have gone wrong, narrative analysis by clinical experts, consultation with the health care sector, and development and pilot testing of corrective strategies. Criteria for deciding which incidents require a population-level response are outlined. Discussion: The incremental cost of a population-based response function is modest compared with the 'reporting' element. Combining clinical and human factors expertise and a systematic approach underpins the creation of credible risk identification processes and the development of preventive and corrective strategies.
Keywords: Incident reporting and analysis; patient safety; risk management; medical errors; human factors; adverse events
Rights: © The Author 2015. Published by Oxford University Press in association with the International Society for Quality in Health Care. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (, which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact
RMID: 0030041708
DOI: 10.1093/intqhc/mzv091
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Appears in Collections:Translational Health Science publications

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