Learning from a critical incident reporting system in the pediatric intensive care unit

Background. To record and analyze critical incidents is of paramount importance for any organization dedicated to improving patient safety. Therefore, many hospitals have implemented a critical incident reporting system (CIRS). However, the impact, benefits and use of such CIRS systems on patient safety have often been reported to be unsatisfactory. Aim. What have we learned over the past decade about the effective and optimal use of a CIRS? Material and methods. Following the Yorkshire contributory factors framework, the potential benefits of a CIRS are illustrated with selected examples from the neonatal and pediatric intensive care unit. Based on a literature search in PubMed from January 2000 to December 2014 this article also describes critical factors and concepts for the successful use of a CIRS. Results. A positive mind-set towards errors, high psychological safety and the conviction that a CIRS can be beneficial are important factors to encourage individual health-care personnel to report critical incidents and learn from errors. On the part of the organization, adequate resources of personnel, systematic analysis of the reported incidents as well as dissemination of the results and implementation of safety improvement strategies are critical factors for the effective use of a CIRS. All incidents with potential relevance for patient safety should be reported. The categorization of the reported incidents facilitates the analysis and identification of relevant conclusions. As an organization dedicated to improve patient safety we have to learn from errors as well as from successes. Conclusion. The successful use of a CIRS depends on the motivation of individual health-care providers as well as on organizational features that encourage critical incident reporting.