British Journal of Anaesthesia 105 (1): 69–75 (2010)

doi:10.1093/bja/aeq133

Critical incident reporting and learning

R. P. Mahajan *
Division of Anaesthesia and Intensive Care, Queen’s Medical Centre, Nottingham NG7 2UH, UK
* E-mail: [email protected]

Summary. The success of incident reporting in improving safety, although obvious in

Key points aviation and other high-risk industries, is yet to be seen in health-care systems. An

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† Critical incident reporting, incident reporting system which would improve patient safety would allow front-end
key in improving safety, is clinicians to have easy access for reporting an incident with an understanding that their
under-utilized in health- report will be handled in a non-punitive manner, and that it will lead to enhanced
care systems. learning regarding the causation of the incident and systemic changes which will prevent
it from recurring. At present, significant problems remain with local and national incident
† Reported incidents
reporting systems. These include fear of punitive action, poor safety culture in an
should be handled in
organization, lack of understanding among clinicians about what should be reported, lack
non-punitive manner.
of awareness of how the reported incidents will be analysed, and how will the reports
† The analysis should take ultimately lead to changes which will improve patient safety. In particular, lack of
human factors approach, systematic analysis of the reports and feedback directly to the clinicians are seen as
using standardized major barriers to clinical engagement. In this review, robust systematic methodology of
framework. analysing incidents is discussed. This methodology is based on human factors model,
† Feedback, regular and and the learning paradigm which emphasizes significant shift from traditional judicial
detailed, is crucial in approach to understanding how ‘latent errors’ may play a role in a chain of events which
engaging clinicians ‘in can set up an ‘active error’ to occur. Feedback directly to the clinicians is extremely
the loop’. important for keeping them ‘in the loop’ for their continued engagement, and it should
target different levels of analyses. In addition to high-level information on the types of
incidents, the feedback should incorporate results of the analyses of active and latent
factors. Finally, it should inform what actions, and at what level/stage, have been taken
in response to the reported incidents. For this, local and national systems will be required
to work in close cooperation, so that the lessons can be learnt and actions taken within
an organization, and across organizations. In the UK, a recently introduced speciality-
specific incident reporting system for anaesthesia aims to incorporate the elements of
successful reporting system, as presented in this review, to achieve enhanced clinical
engagement and improved patient safety.
Keywords: medical errors; quality assurance, health care; risk management; safety

Patient safety has been, and still is, a cause for concern in Incident reporting systems
health-care systems all over the world, including the NHS.
Investigation of critical incidents was first used in the 1940s
Every year, 900 000 incidents and near misses are reported
by Flanagan2 as a technique to improve safety and perform-
around NHS care, 2000 of which result in death. Additional
ance among military pilots. Cooper and colleagues,3 in 1978,
hospital stay costs are approximately £2 billion a year, and
used a ‘modified critical incident technique’ in which they
the negligence claims amount to an extra £400 million a
interviewed anaesthetists and obtained descriptions of pre-
year.1 Incident reporting systems have been a key tool to
ventable incidents. Individual departments of anaesthesia
improve safety and enhance organizational learning from
now have systems in place to record and discuss adverse
incidents in a range of high-risk organizations (commercial
incidents and near misses with a view to improve patient
aviation, rail industry, and others). Although incident report-
safety by learning from these incidents.4
ing has been instituted in health-care systems in many
The main reason for reporting incidents to improve patient
countries for sometime now, similar positive experience is
safety is the belief that safety can be improved by learning
yet to be fully realized.
from incidents and near misses, rather than pretending
In this article, I aim to review the essential components of
that they have not happened.5 In the last two decades,
a successful incident reporting system, framework for analys-
authors have highlighted the need to gather information
ing the reported incidents, and current understanding of bar-
which can be used to improve hospital systems to minimize
riers and enablers to successful incident reporting.

& The Author [2010]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: [email protected]
BJA Mahajan

errors in healthcare,6 and many strategies and tools have reduce errors. However, as admitted by the authors, and
also been developed to reduce errors.7 The calls have been pointed out in the accompanying editorial,15 the analyses
made by quality and safety organizations, and the consu- were significantly hampered by the quality of the reports.
mers of health-care systems,8 for incident reporting to There is no doubt that good ‘quality’ of reports is a definite
better understand errors and their contributing factors.9 – 11 prerequisite for meaningful analysis. For this, engagement
Internationally, WHO has work in progress to develop guide- of clinicians, in particular doctors, is crucial. Lack of engage-
lines for implementing effective reporting systems.12 ment from doctors and under-utilization of a potentially
A successful translation of incident reporting to learning valuable national resource (RLS) were highlighted in the
the lessons depends upon four basic activities relevant to report of the Health Committee of House of Commons on
an iterative loop.13 Patient Safety.16 This committee has called for efforts to be

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made at all levels to enhance clinical engagement in incident
(i) Data input. Lessons have been learnt from the avia-
reporting.
tion industry that the systems for data input need
to be independent and non-punitive to enhance
Analysis of the reported incidents
learning culture.
(ii) The data. The way in which information is gathered A good quality report should lend itself for detailed analysis
and handled is extremely important in determining of the chain of events that lead to the incident. This knowl-
the quality of the report. Systems which have too edge can then be used to consider what interventions, and
many closed questions do not allow free expression at what level in the chain, can prevent the incident from
of ‘what actually happened’. It is vital that the staff occurring again. The concept and proposed framework of
are given opportunity to narrate their own version of investigating and analysing clinical incidents, as reviewed
events. Such data would reflect true nature of the in the following, highlight the areas of information which a
incident, better chronology of events, and would good quality report should be able to capture.
give better feel for the multitude of factors that link In the context of individual and organizational factors,
in the evolution of an incident. often a complex chain of events can be seen that lead to
(iii) Analysis. This phase turns a report into a lesson. This an adverse outcome.17 – 19 It has been argued that the com-
key step requires experts from the speciality, and prehensive analysis of incidents must pay attention to
human performance (or safety), to work together to psychological and human factors in the nature, mechanisms,
interrogate data and generate meaningful learning and causes of the error.6 In this regard, the national report-
outcomes. The analysis phase is probably the length- ing systems have to work alongside the local risk manage-
iest and will require the experts to link different com- ment structures for comprehensive analyses and
ponents of the system and the front-end failures that cross-learning from the incidents. Therefore, it becomes
lead to an incident. It is important that a standar- logical that a standardized framework is used at all levels
dized methodology is adopted at this stage (see for analysis of the incidents.
below). A high-level analysis of the number and kinds of incidents
(iv) Feedback. All parties involved must be prepared to can be performed at the national level, and disseminated
share ideas, abandon defensiveness, and put blame widely. This has the advantage of highlighting the areas for
and recriminations aside. The goal of feedback must improvement (e.g. medication errors, retained throat
be to learn from mistakes, and to ensure that the packs), and for further focus by national organizations to
systems are improved for better patient safety in trigger further actions such as raising awareness, research,
the future. The feedback should be through multiple audits, training initiatives, curriculum, and specific guidelines.
sources right from the high-level managerial staff to However, such high-level analyses are not sufficient, on their
the front-end clinical staff. It is extremely important own, to improve safety at the local level. Local safety initiat-
that all staff can see something positive coming out ives of investigating and analysing incidents are extremely
of the incident reporting for them to continue to par- important to get into the root cause of the incidents and
ticipate in the process. how these can be prevented in the future.

In the UK, subsequent to two seminal reports (‘To Err Is

Human’ and ‘An Organization with a Memory’; 2000),10 11 The paradigm for analysis and learning
in 2001, the National Patient Safety Agency (NPSA) set up a The traditional approach of quick judgements and routine
reporting and learning system (RLS) for the NHS. This assignment of blame often obscure a more complex truth.
system is generic for all the specialities, and to date, has Also, the usual practice of analysing only those incidents
accumulated over 4 million incidents. Catchpole and col- which lead to actual patient harm, in fact, misses big oppor-
leagues14 recently reviewed more than 12 000 anaesthesia- tunities to learn from near misses, or where an incident was
related incidents reported to RLS. The review provided effectively managed without actual harm. Hence, the learn-
extremely useful insight into the kinds of incidents that ing paradigm for incident reporting has to be shifted from the
had been reported to RLS, and therefore, highlighted the traditional ‘judicial’ approach towards a mutual search for
areas of practice where further efforts are required to opportunities for improvement.

70
Incident reporting BJA
Human factors approach
Table 1 Framework as proposed by Vincent and colleagues24 for
The causation of a safety incident which, at first, is identified analysing critical incidents
by an obvious departure from good practice, or active fail-
ures, often has a number of factors related to the working Main factors Contributory factors
environment and wider organizational context working in Institutional Economic pressures, regulations, NHS
the background and influencing the outcome. The ‘human executive, clinical negligence schemes
factors’ approach focuses on the human component within Organizational Financial priorities, structure, local policies,
complex organizational (socio-technical) systems. Thus, it standards, safety culture

has less focus on the individual who makes an error and Work Staffing, skill mix, workload, shift patterns,
environment design, equipment availability and
more on the pre-existing organizational factors that set up

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maintenance, support
the conditions for an error to occur.20 – 22 The approach,
Team factors Communication, supervision, team culture
based on Reason’s model of organizational accidents and
Individual Knowledge, skills, competence, health
adapted for medical settings,20 – 24 allows examination of
Task factors Task design, availability and use of protocols,
the chain of events that lead to an accident. test results, patient notes—accuracy and
The contribution of human decisions, actions, or both to availability
an accident can be due to active failures, latent failures, or Patient factors Complexity and seriousness, language,
both.20 Active failures are unsafe acts or omissions per- communication, personality, social factors
formed by the front-end workers (anaesthetists, surgeons,
nurses), and these include slips (wrong label, wrong
syringe), cognitive failure (memory lapses, ignorance, mis- organization. Hence, the senior clinicians and managers
reading a situation), or violations (deviations from safe prac- may influence a team’s performance by influencing the
tices, procedures, or standards). Latent failures,22 in the ‘work environment’, which includes factors such as staffing
context of health-care systems, refer to decisions taken by level, working hours, equipment availability and mainten-
senior management or clinicians, which create the con- ance, guidelines and protocols, and education and training.
ditions in an organization for unsafe acts to occur; these con- Finally, external factors such as political climate and priori-
ditions include inadequate or inappropriate staffing, heavy ties, financial constraints, regulatory bodies, and public
workload, poor supervision, stressful environment, poor com- expectation may have a powerful effect on the working of
munication, poor maintenance of equipment, and conflict of an organization.
priorities (finance vs clinical need). Hence, in the analyses of The framework for analysis can also be taken to under-
adverse events, a systematic approach of understanding stand what components of information are required in a
the anatomy of evolution or generation of incidents, and a good quality report to allow a detailed, systematic, and
hierarchy of the factors which are involved, should be meaningful analysis. Crucially, the framework provides the
undertaken. researchers and the risk managers a formal structure for col-
For healthcare, Vincent and colleagues25 have described a lection of information and analysis of critical incidents, where
framework for analysing critical incidents. This framework rather than focusing mainly on the actions of the front-line
includes factors of relevance to medicine by combining the staff, the emphasis is on examining the whole gamut of
strengths of Reason’s model of organizational accidents20 21 possible influences. The safer practice can only come from
with socio-technical pyramid of Hurst and Ratcliffe.26 – 29 acknowledging all the possible factors in the potential for
The framework has been summarized in Table 1. In this error, and building in multi-level error reduction strategies
framework, the hierarchy of factors has been derived from at every stage of the chain that leads to generation of an
previous publications,6 17 – 19 22 23 29 30 and includes the error.6 This comprehensive approach of multiple levels of
factors which are known to influence clinical practice and intervention requires the clinicians and the managers to sig-
outcome. In this hierarchy of factors, patients and staff as nificantly shift away from the often practiced, and rarely
individuals are at the front-end (bottom) of the factors, effective, approach of one-level of intervention (e.g. staff
team factors and working conditions in the middle, and training or tightening protocols).
organizational/institutional factors at the top. The condition
of the patient, clearly, is an important direct predictor of
outcome. Also, the adverse events are more likely to occur Components of incident analysis
when the patient is already seriously ill.31 32 The experience, A clear definition is required of which incidents should be
training, and familiarity with the working environment of the reported and investigated. An incident that leads to patient
staff may also be influential. Each member of the staff is part harm always gets investigated according to its seriousness
of a team, and his/her performance may be influenced by as per local governance policies. In this regard, some inves-
other members of the team, and how teams are organized, tigations are started almost immediately. However, this
and how they support, supervise, monitor, and communicate process should not underestimate the potential of analysing
with each other. The team performance, in turn, is influenced incidents that are near misses, or which have not led to
by management decisions made at a higher level in the patient harm.

71
BJA Mahajan

The elements of an investigative or analytic process, as in implemented incident reporting can detect more preventable
practice, are summarized in the following.13 adverse events than medical record review,35 and it is more
cost-effective.36
Identifying the most obvious active failure(s) The medical records, although reasonably good at
The active failures are also known as care management describing adverse events, rarely document near misses. In
problems (CMP). These include delayed diagnosis, inadequate practice, near misses occur more frequently than the
handover, failure to monitor, lack of preoperative check, pro- adverse events37 and provide equally valuable information
tocol violation, incorrect treatment, not seeking help, for drawing up of important clinical lessons without the det-
inadequate supervision, etc. rimental consequences of an adverse event.10 11 Hence,
reporting of near misses provides valuable information for

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Framing the problem systems improvement without patients or staff having suf-
This is not straightforward. Often the problem originates at a fered the consequences of adverse events.
time point which is earlier than the time point at which the Despite the known and well-advertised strengths of the
problem occurs. Therefore, accurate assessment of chronol- incident reporting systems, under-reporting, in particular by
ogy and the details of the events leading on to the incident doctors, remains a significant problem. It is possible that
is important in framing the problem. the incidents are just not recognized, or are not simply docu-
mented properly.38 However, there may be deeper cultural
Defining the problem (what, how, and why) issues acting as barriers to incident reporting. The rates of
In addition to the reported incident, case notes studies and adverse events are estimated to range between 2.9% and
interviews of the key staff members may be undertaken. 16.6% in acute care hospitals.39 It is therefore only logical
The line of enquiry should first determine exactly what hap- to assume that the doctors and the nurses working in hospi-
pened in terms of CMPs and chronology of the events. In the tals will be familiar with these events, and would have come
next stage, it should establish, without being punitive, how it across and reported them. In a recent study,40 despite most
happened. All important acts or omissions made by staff, and staff being aware of the existence of an incident reporting
with hindsight the important chain of events which set up system, 25% did not know how to access an incident form,
the conditions for the incident to occur. Subsequent line of and more than 40% of consultants and registrars had
enquiry should elicit the reasons behind certain acts or omis- never completed a report.
sions. The next step is to define why. For each CMP, contribu- The research has shown that, in general, only a small per-
tory factors, as outlined in the framework, should be centage of doctors report incidents formally.41 42 One of the
explored. These could be specific contributory factors at reasons could be unfamiliarity with the process.43 Other
different levels (e.g. lack of knowledge or training at individ- factors which have been identified are cultural issues such
ual level, unavailability of protocols at task level, poor com- as fear of punitive action,44 45 legal ramifications, and dis-
munication at team level, or inadequate staffing at crimination at the workplace.46 Poor reporting practices by
organizational level). The specific factors will need to be dis- doctors may also reflect prevailing deeply entrenched belief
tinguished from, or studied in context with, general contribu- in medicine that only bad doctors make mistakes.
tory factors such as poor safety culture within an Other factors responsible for poor reporting are related to
organization, overall poor communication, poor training, lack of clarity regarding what should be reported, and how
overstretched staff rotas, or faulty/incomprehensible the reports might lead to improvement in the existing
guidelines. systems.42 47 – 51 A recent study has confirmed the commonly
A separate analysis should be carried out for each CMP observed phenomenon that the incidents which were
using a standardized framework. The final analysis will immediate, and often witnessed (e.g. falls, equipment prob-
report summary of chronology, CMPs, and their contributory lems, drug errors) are better reported than the incidents
causes, and give recommendations for further actions for which had gradual development, and could not be assigned
each contributory factor (in particular, the general contribu- to a single causative factor, or were considered to be known
tory factors). complications of hospitalization (hospital acquired infections,
deep vein thrombosis).40 Many staff do not consider near
misses to be reportable incidents, which are a rich source
Strengths, limitations, barriers,
for learning.37 Also many doctors do not consider omission
and enablers of medication to be reportable, which again indicates lack
Among different strategies to gather information and reduce of essential knowledge about what should be reported,
errors,7 review of a randomly selected, or targeted, sample of given that acts of omission have been implicated in twice
medical records has also been used to identify problem as many adverse events as acts of commission.52 Organiz-
areas. However, because of the limitations in the exiting ational factors which make reporting difficult (long forms,
classification system,33 infrequently occurring errors may insufficient time, and no feedback) have also been identified
not be picked up using this method. One of the strengths as major barriers to reporting.41
of incident reporting is that it tends to capture more contex- Studies that have shown to improve incident reporting
tual information about the incidents.34 Also, successfully have used strategies of intense facilitation, either through

72
Incident reporting BJA
ward rounds or staff reminders.35 36 53 The level of reporting anaesthesia between professional bodies and a Department
in an organization has also been correlated with the existing of Health organization at the national level, to improve
safety culture.54 Therefore, at organizational level, any effort patient safety, is unique in the world. The evidence that
to improve incident reporting and learning should begin with this endeavour will, in fact, enhance the level and quality
assessment of prevailing safety culture within an organiz- of reporting, and safety culture, within and across NHS hospi-
ation, and long-term, sustained programme of improving it. tals, will be instrumental in triggering other clinical special-
The key to the success of incident reporting systems in ities to follow the lead.
improving patient safety lies in the fact that the front-line
clinician must know and believe that the reported incidents
will not end up in a ‘dark hole’, but will be analysed in a sys-
Conflict of interest

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tematic non-punitive manner, and will result in actions which Professor Ravi Mahajan is Chairman of Safe Anaesthesia
will ultimately improve patient safety. At present, most of the Liaison Group at the Royal College of Anaesthetists.
world class reporting systems in healthcare have a long way
to go in engaging clinicians. Keeping the clinicians ‘in the
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