Reporting and Learning Systems for Patient Safety

Abstract

Safety in healthcare is arguably a constantly moving target. The field of patient safety has expanded and as a result, more types of harm are now preventable. Healthcare providers need to be able to achieve ever-evolving targets dealing with a seemingly infinite variability of safety issues. Therefore, they need to analyze situations and take appropriate actions that fit specific contexts and settings. Two systems related to learning systems for patient safety are highlighted in this chapter. Firstly, we examine registration, reporting, and learning systems for patient safety incidents and examine insights from the literature and practice regarding how reporting systems should be constructed. The various requirements of a learning system are discussed, including shifting from a centralized approach, where experts serve as intermediaries, to a decentralized unit-based approach, as well as a shift from recording/data gathering to learning. Subsequently, we discuss our experiences in organizing an incident learning system—including examples of successes and barriers we encountered in implementing a system based on findings from the literature translated to the context of the Antwerp University Hospital. Secondly, we discuss an approach for developing a learning culture using an internationally recognized nurse-sensitive patient outcomes benchmarking dataset embedded in a professional practice model to align quality and patient safety improvement efforts across all levels of our hospital. The second strategy was part of our journey to nursing excellence as we worked toward Magnet hospital designation.