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The purpose of this paper is to explore the re-development process of the Swedish Rescue Services Incident Reporting System from an organizational learning perspective with the purpose to suggest what is needed to enable long-term learning from rescue operations.

The study is carried out as a case study relying on interviews, participant observation and workshop methods. The study case is the Swedish Incident Reporting System.

The objectives expressed by the central agency leading the studied process aimed at implementing double-loop learning objectives by revising the incident reports and to improve future operations accordingly. In practice this objective was lost along the way, with the agency focussing on cosmetic changes to the report such as terminology, attributes and labels. Meanwhile the local rescue services expressed different and concrete needs, requiring new system functionality, case/experience based learning, process improvements and organizational development. A number of suggestions of such measures are provided by the study, to be used by rescue services and other response organizations.

The case stands out because the re-development process is driven by one stakeholder, with the ambition to include multiple stakeholders’ needs. The study should be of specific interest to fire rescue services world-wide. However, considering that many tasks, learning and evaluation aspects of rescue operations are similar regardless of type of first responder involved (e.g. in firefighting, traffic accidents, and cardiac arrests), the results are also of interest to emergency management in general.

This research paper aims to examine how incident‐reporting systems function and particularly how the steady growth of high‐priority incidents and the semi‐exponential growth of low‐priority incidents affect reporting effectiveness. Social pressures that can affect low‐ and high‐priority incident‐reporting rates are also examined.

The authors reviewed the incident‐reporting system literature. As there are few studies of information security reporting systems, they also considered safety‐reporting systems. These have been in use for many years and much is known about them. Safety is used to “fill in the gaps”. The authors then constructed a system dynamics computer simulation model. The model is used to test how an incident‐reporting system reacts under different conditions.

Incident reporters face incentives and disincentives based on effects on through‐put but have limited knowledge of what is important to the organization's security. Even if a successful incident‐reporting policy is developed, the organization may become the victim of its own success, as a growing volume of reports put higher pressure on incident‐handling resources. Continuously hiring personnel is unsustainable. Continuously improving automated tools for incident response promises more leverage.

The challenges in safety may not be the same as those in information security. However, the model does provide a starting‐point for further enquiries into information security reporting systems.

An examination of basic factors that affect information security reporting systems is provided. Four different policies are presented and examined through simulation scenarios.

The purpose of this study is to assess attitudes toward and use of an electronic adverse incident reporting system in all four hospitals in one National Health Service Scotland Health Board area.

A questionnaire was used to assess medical consultants', managers', and nurses' attitudes and perceptions about electronic adverse incident reporting. Actual adverse incident reporting data were also analysed.

The main findings from this study are that consultants, managers, and nurses all had positive attitudes about responsibility for reporting adverse incidents. All respondents indicated that the design of and information collected by the electronic adverse incident reporting system (Datix) was adequate but consultants had more negative attitudes and perceptions than managers and nurses about Datix. All respondents expressed negative attitudes about the amount and type of feedback they receive from reporting, and consultants expressed more negative attitudes about how Datix is managed than managers and nurses. Analysis of adverse incident reporting data found that the proportion of consultants using Datix to report incidents was significantly lower than that of managers and nurses.

The findings suggest that there are no additional barriers to incident reporting associated with the use of a bespoke electronic adverse incident reporting system as compared to other types of systems. Although an electronic adverse incident reporting system may be able to increase incident reporting and facilitate organisational learning by making it easier to report incidents and analyse incident reporting data, strong leadership within hospitals/healthcare professions (or healthcare subcultures) is still required in order to promote and sustain incident reporting to improve patient safety.

This is the first study to investigate attitudes toward and reporting behaviour on a bespoke electronic adverse incident reporting system in hospitals.

There are three main objectives of the research presented in this paper: to examine the challenges of using an electronic adverse incident recording and reporting system; to assess the method of using a prevention appraisal and failure model; and to identify the benefits of using quality costs in conjunction with incident reporting systems.

Action diary, documentation and triangulation are used to obtain an understanding of the challenges and critical success factors in using quality costing within an adverse incident recording and reporting system.

The paper provides healthcare professionals with the critical success factors for developing quality costing into an electronic adverse incident recording and reporting system. This approach would provide clinicians, managers and directors with information on patient safety issues following the effective use of data from an electronic adverse incident reporting and recording system.

This paper makes an attempt of using a prevention, appraisal and failure model (PAF) within a quality‐costing framework in relation to improving patient safety within an electronic adverse incident reporting and recording system.

The purpose of this paper is to examine the usability and potential of incorporating quality costs into an electronic adverse incident recording system within a healthcare sector.

The paper is a general review and a discussion of an electronic adverse incident‐recording system into the potential benefits and restrictions was undertaken. Articles containing both information systems and quality costs were reviewed in order to explore the potential of linking information against patient safety issues.

The paper finds that quality costs is a valid and useful approach for measuring the impact of individual adverse incidents or trends in order to support managers and clinicians to develop appropriate action plans to reduce levels of patient harm and thereby improve patient safety. The paper also shows that quality costs can be used to support managers and clinicians and are commercially designed to improve the detection, investigation and action planning to improve service quality and patient safety.

Quality costs can be used as a driver for identifying potential high impact quality and patient safety projects within a healthcare setting.

This paper provides useful information for designers of electronic adverse incident‐reporting systems to support managers and clinicians to utilise the benefits of quality costing in order to strengthen and re‐focus patient safety issues in healthcare.

In the past, people were usually seen as the weakest link in the IT security chain. However, this view has changed in recent years and people are no longer seen only as a problem, but also as part of the solution. In research, this change is reflected in the fact that people are enabled to report security incidents that they have detected. During this reporting process, however, it is important to ensure that the reports are submitted with the highest possible data quality. This paper aims to provide a process-driven quality improvement approach for human-as-a-security-sensor information.

This work builds upon existing approaches for structured reporting of security incidents. In the first step, relevant data quality dimensions and influencing factors are defined. Based on this, an approach for quality improvement is proposed. To demonstrate the feasibility of the approach, it is prototypically implemented and evaluated using an exemplary use case.

In this paper, a process-driven approach is proposed, which allows improving the data quality by analyzing the similarity of incidents. It is shown that this approach is feasible and leads to better data quality with real-world data.

The originality of the approach lies in the fact that data quality is already improved during the reporting of an incident. In addition, approaches from other areas, such as recommender systems, are applied innovatively to the area of the human-as-a-security-sensor.

The purpose of this paper is to present the challenges and gaps in using an electronic adverse incident recording and reporting system from a commercial supplier to an acute health care setting.

The paper used action diary, documentation and triangulation to obtain an understanding of the challenges and gaps.

The paper provides health care with further understanding of the complexity, challenges and gaps of using an electronic adverse incident recording system to improve patient safety.

This paper explains the important views of clinicians and managers in relation to improving patient safety by using an electronic adverse incident management system.

Hospital nurse managers are in the middle. Their supervisors expect that they will monitor and discipline nurses who commit errors, while also asking them to create a culture that fosters reporting of errors. Their staff nurses expect the managers to support them after errors occur. Drawing on interviews with 20 nurse managers from three tertiary care hospitals, the study identifies key exemplars that illustrate how managers monitor nursing errors. The exemplars examine how nurse managers: (1) sent mixed messages to staff nurses about incident reporting, (2) kept two sets of books for recording errors, and (3) developed routines for classifying potentially harmful errors into non-reportable categories. These exemplars highlight two tensions: the application of bureaucratic rule-based standards to professional tasks, and maintaining accountability for errors while also learning from them. We discuss how these fundamental tensions influence organizational learning and suggest theoretical and practical research questions and a conceptual framework.

Incident reporting systems are commonly deployed in healthcare but resulting datasets are largely warehoused. This study explores if intelligence from such datasets could be used to improve quality, efficiency, and safety.

Incident reporting data recorded in one NHS acute Trust was mined for insight (n = 133,893 April 2005–July 2016 across 201 fields, 26,912,493 items). An a priori dataset was overlaid consisting of staffing, vital signs, and national safety indicators such as falls. Analysis was primarily nonlinear statistical approaches using Mathematica V11.

The organization developed a deeper understanding of the use of incident reporting systems both in terms of usability and possible reflection of culture. Signals emerged which focused areas of improvement or risk. An example of this is a deeper understanding of the timing and staffing levels associated with falls. Insight into the nature and grading of reporting was also gained.

Healthcare incident reporting data is underused and with a small amount of analysis can provide real insight and application to patient safety.

This study shows that insight can be gained by mining incident reporting datasets, particularly when integrated with other routinely collected data.

The purpose of this study is to determine the effectiveness of incident reporting within the Department of Gynaecology at Trafford General Hospital.

A list of all reported clinical incidents in relation to gynaecology at the Trafford General Hospital over a period of two years (January 2005 to December 2006) was obtained. The complaints and claims related to gynaecology were also obtained for the same time period. All complaints and claims were correlated with the reported adverse incidents.

Of the reported 111 adverse incidents, none resulted in either complaint or claim. None of the complaints resulted in claims but there was no corresponding incident reporting. All the claims were directly related to surgical procedures but no incident reporting was done either. The nursing staff filled in all the 111 adverse incident forms.

This study is only limited to adverse incidents in gynaecology over a short period of time (two years) at a District General Hospital.

This study demonstrates the need to stress the importance of incident reporting to the doctors. It is suggested that a session be dedicated to incident reporting as a part of in‐house training for medical staff of all grades.

This paper highlights the need to impress on the medical staff about the importance of adverse clinical incident reporting.