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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.

This paper reports on a regionally based UK study uncovering what has worked well in learning from adverse incidents in hospitals. The purpose of this paper is to review the incident investigation methodology used in identifying strengths or weaknesses and explore the use of a database as a tool to embed learning.

Documentary examination was conducted of all adverse incidents reported between 1 June 2011 and 30 June 2012 by three UK National Health Service hospitals. One root cause analysis report per adverse incident for each individual hospital was sent to an advisory group for a review. Using terms of reference supplied, the advisory group feedback was analysed using an inductive thematic approach. The emergent themes led to the generation of questions which informed seven in-depth semi-structured interviews.

“Time” and “work pressures” were identified as barriers to using adverse incident investigations as tools for quality enhancement. Methodologically, a weakness in approach was that no criteria influenced the techniques which were used in investigating adverse incidents. Regarding the sharing of learning, the use of a database as a tool to embed learning across the region was not supported.

Softer intelligence from adverse incident investigations could be usefully shared between hospitals through a regional forum.

The use of a database as a tool to facilitate the sharing of learning from adverse incidents across the health economy is not supported.

Records of violent incidents were retrospectively analysed to identify trends associated with violent incidents within an NHS medium secure psychiatric unit. Over a 12‐month period, 116 incident forms related to 112 incidents. These incidents were compared with a study from the previous 12 months within the same unit. Both studies were based upon work from within a high‐security setting (Caldwell and Naismith, 1989). There was a significant reduction in the overall number of violent incidents.The majority of incidents continued to occur within the intensive care admission unit. There continued to be a higher incidence of assaultive behaviour throughout the afternoon and evening. Seasonal variations demonstrates a reduction of incidents throughout the autumn and winter months compared with the previous year, and a significant change in the number of incidents that occurred during the summer.There remain opportunities for comparison with other secure units and further refinement of the methodology.

The purpose of this paper is to determine the prevalence of feedback following adverse clinical incident reporting among trainee doctors in obstetrics and gynaecology within the Northwestern Deanery of England.

An anonymous questionnaire was circulated among the Specialist Registrar trainees within the specialty attending a regional teaching session. The questionnaire was analysed.

There were 50 responses, of those 45 (90 per cent) had been involved in an adverse clinical incident; 44 had submitted an incident form related to the incident. Three had submitted incident forms without being involved in an adverse incident. Most (80 per cent) had submitted an incident form as well as a related statement. Feedback was available to 23 (51 per cent) of those involved in adverse incidents. More of the senior trainees received feedback than the junior ones. A lecture on clinical incident reporting was available to only 35(70 per cent) of the respondents on the hospital induction day at their latest clinical placement.

This study is limited to adverse clinical incident reporting among the trainees in a single specialty within one deanery in UK; hence the small numbers.

This study demonstrates the presence of awareness regarding adverse incident reporting among the trainees in a high‐risk specialty. It also shows the suboptimal rate of feedback following adverse incident reporting, which does not encourage a learning environment. It is suggested that a lecture should be dedicated to incident reporting at the junior doctors' induction day programme in every hospital.

This paper highlights the lack of adequate feedback following adverse clinical incident reporting.

In order to improve working methods, this study proposes a method for the analysis of medication incidents and the systematic planning of error‐proofing (EP) countermeasures, in the hope that it might contribute to a reduction in medication incidents.

In order to simplify the process of planning EP countermeasures, the following approaches are employed in this study. Improvement elements are extracted in order to plan EP countermeasures. The improvement elements that caused the error‐factor are called improvement objects, and the authors designed the extraction set of improvement objects. The authors correlated the improvement objects with recommended EP solutions. Finally, these parameters are collated. Moreover, these tools are summarized as a procedure for analysis of such incidents and for the creation of appropriate EP countermeasures.

Using this approach, this paper suggests four steps to reduce medical incidents. The proposed procedure can facilitate the planning of EP countermeasures and can reduce the rate of medical incidents.

It can be surmised that the proposed method can serve as a useful means for planning EP countermeasures and reducing the number of medication incidents. On the other hand, there are various countermeasures which can be planned for one incident by applying the proposed method.

The relationship between Error factors and improvement objects were then clarified through utilizing maps. Furthermore, a list that clearly indicates which EP solutions should be adopted for the improvement objects were suggested. There is, therefore, a significant difference between the proposed and the conventional method, and this makes it possible to plan the EP countermeasures easily.

The current national patient safety strategy for the National Health Service (NHS) in England states that actions need to be taken to support the development of a patient safety culture. This includes that local systems should seek to understand staff perceptions of the fairness and effectiveness of serious incident management. This study aims to explore the perspectives of patient safety professionals about what works well and what could be done better to support a patient safety culture at the level of Trust strategy and serious incident governance.

A total of 15 professionals with a role in serious incident management, from five mental health trusts in England, were interviewed using a semi-structured interview guide. Thematic analysis and qualitative description were used to analyse the data.

Participants felt that actions to support a patient safety culture were challenging and required long-term and clinical commitment. Broadening the scope of serious incident investigations was felt to be one way to better understand patient safety culture issues. Organisational influences during the serious incident management process were highlighted, informing approaches to maximise the fairness and objectivity of investigation findings.

The findings of this study offer original insights that the NHS safety system can use to facilitate progression of the patient safety culture agenda. In particular, local mental health trusts could consider the findings in the context of their current strategic objectives related to patient safety culture and operational delivery of serious incident management frameworks.

The need to develop effective approaches for responding to healthcare incidents for the purpose of learning and improving patient safety has been recognised in current national policy. However, research into this topic is limited. This study aims to explore the perspectives of professionals in mental health trusts in England about what works well and what could be done better when implementing serious incident management systems.

This was a qualitative study using semi-structured interviews. In total, 15 participants were recruited, comprising patient safety managers, serious incident investigators and executive directors, from five mental health trusts in England. The interview data were analysed using a qualitative-descriptive approach to develop meaningful themes. Quotes were selected and presented based on their representation of the data.

Participants were dissatisfied with current systems to manage serious incidents, including the root cause analysis approach, which they felt were not adequate for assisting learning and improvement. They described concerns about the capability of serious incident investigators, which was felt to impact on the quality of investigations. Processes to support people adversely affected by serious incidents were felt to be an important part of incident management systems to maximise the learning impact of investigations.

Findings of this study provide translatable implications for mental health trusts and policymakers, informed by insights into how current approaches for learning from healthcare incidents can be transformed. Further research will build a more comprehensive understanding of mechanisms for responding to healthcare incidents.

The present experimental study aims to investigate when a food safety incident occurs, how country image influences consumers' trust and purchase intention, as well as the relationship between trust and purchase intention.

Participants (N = 1,590) were randomly allocated into one of the eight conditions [(country competence: high vs low) × (country warmth: high vs low) × (clean green image: high vs low)], read the corresponding country image descriptions, and rated measures on trust in food safety and quality, and purchase intention of fruit imported from this exporting country before and after reading a fictional food safety incident scenario.

Results showed that the food safety incident led to a significant decrease in trust and purchase intention across all conditions. However, trust in food safety and quality, and purchase intention were still higher in high competence, warmth or clean green image conditions. The decreased magnitude of trust in food safety was larger when country competence and clean green image was high, and when country warmth was low. Food safety incident caused purchase intention to become more dependent on trust in food safety than food quality.

This study provides a novel insight into the impacts of food safety incidents on consumers' responses in different country image contexts including the human-related and environment-related dimensions.

The purpose of this paper is to examine the effectiveness of using structured reflection via the critical incident analysis method to develop multicultural awareness and intercultural empathy in undergraduate-level pre-service teachers. This research is important, given the striking demographic mismatch between students and teachers in US schools.

This study adopts a convergent parallel mixed methods research design that combines both qualitative analysis of completed written critical incident analysis assignments and quantitative analysis of responses from a brief survey.

In most cases, engaging with the critical incident analysis method did lead participants reexamine their own experiences and develop a better understanding of their own biases and actions. While students followed different pathways with the assignment, participants were able to better understand the crucial role that teachers play in creating a space that values and welcomes diversity for the benefit of all students.

This study diverges from future research on the critical incident analysis method by asking students to examine specific moments from their past in the process of deep, targeted self-reflection.

New patient safety frameworks are being implemented to improve the impact of incident reporting and management across the National Health Service (NHS) in England. This study aims to examine the current practices in this domain of patient safety in a sample of mental health trusts, a setting in which limitations in the current practice of serious incident management have been reported. The authors present key recommendations to maximise the opportunities to improve current incident reporting and management practice.

Ethical approval for the study was granted. A Web-based questionnaire was designed to examine current practices concerning incident reporting and management. It was refined based on consultation. Patient safety incident managers within mental health trusts in England were recruited. Twenty-nine mental health trusts responded, from a total of 51. The questionnaire study data were analysed in Statistical Package for the Social Sciences.

Current approaches used to report and manage incidents have been established and variation in practice demonstrated. A key finding for attention is that the training and education that investigators of serious incidents receive falls short of the recommended minimum national standard of 15 h, with a sample mean of 10.3 h and median of 8.0 h.

Recommendations at a local and national level are presented, which, if implemented, can maximise the impact of incident reporting and management practices in mental health trusts. Future qualitative research is indicated, to understand the perceptual experience and meaning behind the findings across a wider group of stakeholders.