Incident reporting systems in healthcare are a globally established strategy for managing risk and safety. Developed from similar applications in other high-risk industries, incident reports can function to show key failures of systems, organisations and teams, and can be analysed to improve and facilitate risk minimisation. This PhD aims to investigate effective feedback and learning from Centralised Incident Reporting Systems (CIRS) through the lens of The National Reporting and Learning System.
An evidence review was conducted to explore the current understanding of effective learning from CIRS. Following this, qualitative explorations at local and national level were conducted to explore current practice for generating feedback and learning, the system requirements which facilitate effective learning, and recommendations to facilitate effective learning from incidents.
Expert opinion offered a number of ways in which feedback and learning can be effective, more refined and relevant to front line staff. Learning and reporting are functions of a system in which the culture uplifts staff to naturally do better and want to learn from mistakes. The type of learning output is key to understanding how well key learning can be applied, and by whom.
Findings were synthesised using a constant comparative method to establish themes recurring throughout this work. The Ghulam-Arshad model presented in chapter 5 condenses and links the work across this PhD in the form of input-process-output, to conceptualise the relationship between reporting and learning, and how it is heavily underpinned by context and culture in healthcare organisations.