Analysis of clinical incidents: a window on the system not a search for root causes

Incident reporting lies at the heart of many initiatives to improve patient safety. The UK National Patient Safety Agency (NPSA) 1 has recently launched a national reporting and learning system following substantial piloting and testing across the National Health Service (NHS). In the USA the Agency for Healthcare Research and Quality (AHRQ) made incident reporting the centrepiece of its first patient safety funding programme, investing 25 million in the first year into research in incident reporting systems. 2 The Australian incident monitoring system has amassed a massive database of reports over 15 years. 3 New risk management and patient safety programmes-whether local or national-rely on incident reporting to provide data on the nature of safety problems and to provide indications of the causes of those problems and the likely solutions.