SynthesisThe Milbank quarterly2015
How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review.
Synthesis in The Milbank quarterly, 2015. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 75 papers, 6 of them syntheses that pooled it.
What it found
Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.
The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.
The trial behind it
Trials whose registry record cites this paper, or whose number appears in the abstract. A trial that started after this paper was published is citing it as background, not reporting it.
Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.
Who cites it
75 citing papers in PubMed, 6 syntheses or guidelines pooled it, 205 citations in OpenAlex.
- Strategies and tools to learn from work that goes well within healthcare patient safety practices: a mixed methods systematic review.BMC health services research · 2025Pooled it
- Patient safety incident reporting systems and reporting practices in African healthcare organisations: a systematic review and meta-analysis.BMJ open quality · 2025Pooled it
- Systematic review of types of safety incidents and the processes and systems used for safety incident reporting in care homes.Journal of advanced nursing · 2025Pooled it
- Barriers and facilitators to improving patient safety learning systems: a systematic review of qualitative studies and meta-synthesis.BMJ open quality · 2023Pooled it
- Prevalence and Nature of Medication Errors and Medication-Related Harm Following Discharge from Hospital to Community Settings: A Systematic Review.Drug safety · 2020Pooled it
- Patient Safety Learning Systems: A Systematic Review and Qualitative Synthesis.Ontario health technology assessment series · 2017Pooled it
- From Evidence to Value: Integrating Evidence-Based Medicine, Patient Safety, Quality Improvement, Learning Health Systems, and Value-Based Healthcare.Journal of evaluation in clinical practice · 2026Review
- Nurse-Led Ambient AI Scribe for Patient Safety Incident Investigation Reports (Project NARRATE): Retrospective Pre-Post Comparative Document-Quality Study.JMIR nursing · 2026Article
- Parental involvement in patient safety events in paediatric emergency care: a multi-method analysis.BMJ paediatrics open · 2026Article
- Do patient safety incident investigations align with systems thinking? An analysis of contributing factors and recommendations.BMJ quality & safety · 2026Article
- The role of communication in the operating theatre: attitudes of anaesthesiology trainees.Irish journal of medical science · 2026Article
- Understanding Engagement With Incident Reporting Systems Among NHS Healthcare Professionals: A Cross-Sectional Study.Cureus · 2025Article
- Observational
- Training Hospital Nurses to Write Detailed Narratives and Describe Contributing Factors in Incident Reports: The SAFER Education Program.Joint Commission journal on quality and patient safety · 2025Article
- Developing and evaluating a dental incident reporting system: a user-centered approach to risk management.BMC oral health · 2025Article
- High-risk medication errors: Insight from the UK National Reporting and learning system.Exploratory research in clinical and social pharmacy · 2025Article
- Connected Healthcare System Technology Interventions to Improve Patient Safety by Reducing Medical Errors: A Systematic Review.Global journal on quality and safety in healthcare · 2025Review
- Handling Features of Patient Safety Incident Reporting Software and Shortcomings in Report Processing From Healthcare Professionals' Perspectives: A Cross-Sectional Study With a Qualitative Design.Journal of nursing management · 2025Article
- Decades of failure to prevent harm to patients-where are we going wrong? A mixed methods study of the perspectives of health services staff across Australia and internationally.Frontiers in health services · 2025Article
- Examining psychosocial risks and their impact on nurses' safety attitudes and medication error rates: A cross-sectional study.AIMS public health · 2025Article
15 more citing papers are in PubMed but not listed here.
Corrections and comments
PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.
Authors and funding
3 authors at 2 institutions in 1 country.
Funding
No grant is acknowledged in the PubMed record.
Abstract
contextIncident-reporting systems (IRSs) are used to gather information about patient safety incidents. Despite the financial burden they imply, however,little is known about their effectiveness. This article systematically reviews the effectiveness of IRSs as a method of improving patient safety through organizational learning.
methodsOur systematic literature review identified 2 groups of studies: (1)those comparing the effectiveness of IRSs with other methods of error reporting and (2) those examining the effectiveness of IRSs on settings, structures, and outcomes in regard to improving patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where, and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single-loop and double-loop learning.
findingsIn total, we identified 43 studies, 8 that compared IRSs with other methods and 35 that explored the effectiveness of IRSs on settings, structures,and outcomes. We did not find strong evidence that IRSs performed better than other methods. We did find some evidence of single-loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence of either improvements in outcomes or changes in the latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double-loop learning, that is, a cultural change or a change in mind-set.
conclusionsThe results indicate that IRSs could be more effective if the criteria for what counts as an incident were explicit, they were owned and ledby clinical teams rather than centralized hospital departments, and they were embedded within organizations as part of wider safety programs.
Indexed as
Identifiers
What OpenQuestion holds
Registered trials
Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.