Characteristics of Critical Incident Reporting Systems in Primary Care: An International Survey

J Patient Saf. 2022 Jan 1;18(1):e85-e91. doi: 10.1097/PTS.0000000000000708.


Objective: The aim of the study was to support the development of future critical incident reporting systems (CIRS) in primary care by collecting information on existing systems. Our focus was on processes used to report and analyze incidents, as well as strategies used to overcome difficulties.

Methods: Based on literature from throughout the world, we identified existing CIRS in primary care. We developed a questionnaire and sent it to operators of a purposeful sample of 17 CIRS in primary care. We used cross-case analysis to compare the answers and pinpoint important similarities and differences in the CIRS in our sample.

Results: Ten CIRS operators filled out the questionnaire, and 9 systems met our inclusion criteria. The sample of CIRS came from 8 different countries and was rather heterogeneous. The reporting systems invited a broad range of professions to report, with some also including reports by patients. In most cases, reporting was voluntary and conducted via an online reporting form. Reports were analyzed locally, centrally, or both. The various CIRS used interesting ideas to deal with barriers. Some, for example, used confidential reporting modes as a compromise between anonymity and the need for follow-up investigations, whereas others used smartphone applications and call centers to speed up the reporting process.

Conclusions: We found multiple CIRS that have operated in primary care for many years and have received a high number of reports. They were largely developed in accordance with recommendations found in literature. Developers of future systems may find this overview useful.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Humans
  • Primary Health Care*
  • Risk Management*
  • Surveys and Questionnaires