How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

Milbank Q. 2015 Dec;93(4):826-66. doi: 10.1111/1468-0009.12166.


Context: Incident-reporting systems (IRSs) are used to gather information about patient safety incidents. Despite the financial burden they imply, however,little is known about their effectiveness. This article systematically reviews the effectiveness of IRSs as a method of improving patient safety through organizational learning.

Methods: Our systematic literature review identified 2 groups of studies: (1)those comparing the effectiveness of IRSs with other methods of error reporting and (2) those examining the effectiveness of IRSs on settings, structures, and outcomes in regard to improving patient safety. We used thematic analysis to compare the effectiveness of IRSs with other methods and to synthesize what was effective, where, and why. Then, to assess the evidence concerning the ability of IRSs to facilitate organizational learning, we analyzed studies using the concepts of single-loop and double-loop learning.

Findings: In total, we identified 43 studies, 8 that compared IRSs with other methods and 35 that explored the effectiveness of IRSs on settings, structures,and outcomes. We did not find strong evidence that IRSs performed better than other methods. We did find some evidence of single-loop learning, that is, changes to clinical settings or processes as a consequence of learning from IRSs, but little evidence of either improvements in outcomes or changes in the latent managerial factors involved in error production. In addition, there was insubstantial evidence of IRSs enabling double-loop learning, that is, a cultural change or a change in mind-set.

Conclusions: The results indicate that IRSs could be more effective if the criteria for what counts as an incident were explicit, they were owned and ledby clinical teams rather than centralized hospital departments, and they were embedded within organizations as part of wider safety programs.

Keywords: incident-reporting systems; organizational learning; patient safety; single-loop and double-loop learning.

Publication types

  • Review
  • Systematic Review

MeSH terms

  • Electronic Health Records / statistics & numerical data
  • Humans
  • Medical Errors / prevention & control*
  • Patient Harm / prevention & control*
  • Patient Safety / statistics & numerical data*
  • Quality Improvement / organization & administration*
  • Safety Management / organization & administration*
  • Total Quality Management / organization & administration*