Maximising learning from patient safety incidents in emergency care.

Abstract

In a modern healthcare system, a systems approach to patient safety is essential to learn from incidents and mitigate the risk of avoidable harm to patients. Emergency nurses have an important role in the prevention, identification, reporting, investigation and management of patient safety incidents in the emergency department (ED). This article describes the role of emergency nurses and the ED governance team in patient safety, discusses the interacting work-system factors that contribute to incidents, and introduces the key aspects of the patient safety incident response framework (PSIRF). The author discusses how the PSIRF represents a shift in the way patient safety incidents are managed, with a move away from apportioning blame towards a culture of learning and quality improvement.