Enhancing Safety Culture Through Improved Incident Reporting: A Case Study In Translational Research

The Imperial College Healthcare National Health Service Trust, a large health care provider in London, together with an academic research unit, used a learning health systems cycle of interventions. The goals were to improve patient safety incident reporting and learning and shape a more just organizational safety culture. Following a phase of feedback gathering from front-line staff, seven evidence-based interventions were implemented and evaluated from October 2016 to August 2018. Indicators of safety culture, incident reporting rates, and reported rates of harm to patients and "never events" (events that should not happen in medical practice) were continuously monitored. In this article we report on this initiative, including its early results. We observed improvement on some measures of safety culture and incident reporting rates. Staff members' perceptions of six of the seven interventions were positive. The intervention exercise demonstrated the importance of health care policies in supporting local ownership of safety culture and encouraging the application of rigorous research standards.