Visualising learning from patient safety incidents to promote a blame-free culture: a case study from Al Dhafra Hospitals

Abstract Hospitals worldwide encounter significant challenges in enhancing and maintaining effective incident reporting systems. A fundamental aspect of this improvement is fostering the right culture which facilitates reporting and learning. In this case study, we describe an approach for incident reporting improvement at Al Dhafra Hospitals, SEHA, through the conceptualization of a “garden of improvement.” The garden provides a visualisation of key learning emergent from reported safety incidents to signal to staff the value and importance of their contributions to improving patient safety. To address the barriers to effective incident reporting, we employed three key components: a self-reflection tracking sheet, a visual depiction of the Garden of Improvement, and a reward system. We observed a 17% increase in incident reporting, including a significant jump in near-miss reporting. The proportion of good catch reports also more than doubled, from 3.0% to 6.9%. The implementation of this model has supported interdepartmental collaboration, knowledge sharing, and continuous improvement. To address the barriers to effective incident reporting, we employed three key components: (1) a self-reflection tracking sheet, which is a visual table displayed in the wards and departments that prompts staff to document their reporting activity daily, fostering awareness and accountability; (2) a visual depiction of the key learning emergent from reported incidents to facilitate understanding of lessons learned; and (3) an existing good catch reward system. In this study we observed a 17% increase in overall incident reporting compared to the previous year, including a significant jump in near-miss reporting, which projects an enhanced safety mindset. The proportion of good catch reports also more than doubled, escalating from 3.0% to 6.9%. The implementation of this model has proven to be an effective strategy for fostering interdepartmental collaboration, cultivating a robust reporting culture, enhancing knowledge sharing, and culminating in a more comprehensive approach to incident management and reporting. In addition, the establishment of feedback mechanisms ensures that the model remains adaptive to the evolving needs of staff, thereby supporting continuous improvement within the healthcare environment.