Identifying systems failures in the pathway to a catastrophic event

"We identified areas of concern even within the context of a highly controlled standardised national process. If incident reporting systems include and encourage reports of no-harm incidents in addition to actual patient harm, they can facilitate monitoring the resilience of healthcare processes. Patient safety incidents that produce the most serious harm are often rare, and it is difficult to know whether patients are adequately protected. Our approach provides a potential solution."

Identifying systems failures in the pathway to a catastrophic event: an analysis of national incident report data relating to vinca alkaloids
BD Franklin, SS Panesar, C Vincent, LJ Donaldson
BMJ Quality and Safety, 2014;23:765-772

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