Assessing the quality of patient safety incident investigation reports
Clicks: 4
ID: 315026
2026
Article Quality & Performance Metrics
Overall Quality
Not rated
Combines reader engagement with the AI quality analysis. This
article has not been analysed, so there is no overall score —
reader engagement is measured and shown alongside.
Reader Engagement
Steady Performance
0.9
/100
4 views
1 readers
AI Quality Assessment
Not analyzed
Readership in this journal
SteadyRanked #70 of 106 articles by views in International journal for quality in health care : journal of the International Society for Quality in Health Care
Most read
Least read
Bar heights use a square-root scale.
Mint this article as an NFT
Not yet mintedCreate a permanent, verifiable on-chain record of this article on the Scimatic Network. The NFT is held in your Journament account, and you can withdraw it to your own wallet at any time.
5
SUSD
one-off · no wallet required
Abstract
Abstract Background Between 4% and 17% of hospital inpatients experience a patient safety incident. Many healthcare organisations undertake analysis and investigation of serious incidents to understand them and prevent future occurrences. Tools have been developed to assess investigation quality as a reflection of a health service’s learning and improvement process. However, a broad-scale examination of the quality of investigation reports has not been conducted in Australia. This study aimed to assess the quality of a sample of Australian patient safety incident investigation reports. Methods A deductive, directed content analysis was conducted to assess the quality of 300 incident investigation reports from 56 Australian health services. Each report was assessed on the extent to which they met predefined quality criteria using the Dutch Health and Youth Care Inspectorate (IGZ) scoring instrument and the United Kingdom’s Learning Response Review and Improvement Tool (LRRT). Results A detailed and complete description of events was present in just over half of the reports (57%). There was also variable application of systems approaches to incident causation in the reports. Generally, there was evidence that the people affected were engaged with, the avoidance of blame and counterfactual reasoning was well executed, as was overall writing quality. Areas in need of improvement included identifying contributing factors beyond the staff and local hospital, the use of appropriate scientific literature and using observational insights to enhance understanding of work-as-done–in our sample only 4% used observation techniques to examine healthcare processes. Conclusion This study establishes that stronger foundational, evidence-based approaches to incident investigation are necessary. These approaches include using multiple data sources, like observations of real work, and inclusion of people with skills to apply a systems thinking-driven analytical process to effectively identify contributing factors beyond the individual to drive learning and continuous systemic improvement.
| Reference Key |
openalex_W7162394705
Use this key to autocite in the manuscript while using
SciMatic Manuscript Manager or Thesis Manager
|
|---|---|
| Authors | Lorelle Bowditch, Charlotte J Molloy, Brandon King, Masoumeh Abedi, Samantha Jackson, Mia Bierbaum, Yinghua Yu, Louise Raggett, Paul Salmon, Raghu Lingam, Sandy Middleton, Jeffrey Braithwaite, Johanna Westbrook, Robyn Clay-Williams, Peter D Hibbert |
| Journal | International journal for quality in health care : journal of the International Society for Quality in Health Care |
| Year | 2026 |
| DOI |
10.1093/intqhc/mzag077
|
| URL | |
| Keywords | Keywords not found |
Citations
No citations found. To add a citation, contact the admin at info@scimatic.org
Comments
No comments yet. Be the first to comment on this article.