Visualizing 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 visualization 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.