[Experiences with "incident reporting" at the East Switzerland Childrens Hospital]

Our healthcare system has become a "high-tech" industry and, as a consequence, incidents are almost "normal" events. It is one of the most important obligations in the quality management to get control of these very dangerous and therefore extremely important problems. The Children's Hospital in St. Gallen (Switzerland) introduced in 1998 a reporting system in order to monitor incidents and mistakes and to be able to introduce preventive action. For this we have been using the so called "system approach", i.e. we are not trying to find a guilty person or a single source for a mistake, but we analyze the complete working system involved in the action. According to our experience, such reporting systems have to respect a number of specific rules and prerequisites in order to be successful. The most crucial one is a "change of culture", which means, that we are not looking for a guilty person, but for the weak elements which are responsible for the mistakes in our working systems. In Switzerland a National Foundation for Patient Safety has been created for supporting all the acting professionals in the healthcare system in their challenging task.