Ont Health Technol Assess Ser. 2017 Mar 1;17(3):1-23. eCollection 2017.
A patient safety learning system (sometimes called a critical incident reporting system) refers to structured reporting, collation, and analysis of critical incidents. To inform a provincial working group's recommendations for an Ontario Patient Safety Event Learning System, a systematic review was undertaken to determine design features that would optimize its adoption into the health care system and would inform implementation strategies.
The objective of this review was to address two research questions: (a) what are the barriers to and facilitators of successful adoption of a patient safety learning system reported by health professionals and (b) what design components maximize successful adoption and implementation? To answer the first question, we used a published systematic review. To answer the second question, we used scoping study methodology.
Common barriers reported in the literature by health care professionals included fear of blame, legal penalties, the perception that incident reporting does not improve patient safety, lack of organizational support, inadequate feedback, lack of knowledge about incident reporting systems, and lack of understanding about what constitutes an error. Common facilitators included a non-accusatory environment, the perception that incident reporting improves safety, clarification of the route of reporting and of how the system uses reports, enhanced feedback, role models (such as managers) using and promoting reporting, legislated protection of those who report, ability to report anonymously, education and training opportunities, and clear guidelines on what to report. Components of a patient safety learning system that increased successful adoption and implementation were emphasis on a blame-free culture that encourages reporting and learning, clear guidelines on how and what to report, making sure the system is user-friendly, organizational development support for data analysis to generate meaningful learning outcomes, and multiple mechanisms to provide feedback through routes to reporters and the wider community (local meetings, email alerts, bulletins, paper contributions, etc.).
The design of a patient safety learning system can be optimized by an awareness of the barriers to and facilitators of successful adoption and implementation identified by health care professionals. Evaluation of the effectiveness of a patient safety learning system is needed to refine its design.
患者安全学习系统（有时称为重大事件报告系统）是指对重大事件进行结构化报告、整理和分析。为了为省级工作组关于安大略省患者安全事件学习系统的建议提供依据，开展了一项系统评价，以确定能够优化其在医疗系统中采用并为实施策略提供依据的设计特征。
本评价的目的是解决两个研究问题：（a）卫生专业人员报告的成功采用患者安全学习系统的障碍和促进因素有哪些？（b）哪些设计要素能最大限度地提高成功采用和实施的几率？为回答第一个问题，我们使用了已发表的系统评价。为回答第二个问题，我们采用了范围界定研究方法。
卫生保健专业人员在文献中报告的常见障碍包括害怕受到指责、法律处罚、认为事件报告无助于提高患者安全、缺乏组织支持、反馈不足、对事件报告系统缺乏了解以及对什么构成错误缺乏认识。常见的促进因素包括无指责环境、认为事件报告可提高安全性、明确报告途径以及系统如何使用报告、加强反馈、榜样（如管理人员）使用和推广报告、对报告者的立法保护、匿名报告的能力、教育和培训机会以及关于报告内容的明确指南。患者安全学习系统中能提高成功采用和实施几率的要素包括强调鼓励报告和学习的无指责文化、关于如何报告及报告内容的明确指南、确保系统便于使用、组织发展对数据分析的支持以产生有意义的学习成果，以及通过向报告者和更广泛社区反馈的多种机制（当地会议、电子邮件提醒、公告、书面投稿等）。
通过了解卫生保健专业人员确定的成功采用和实施的障碍及促进因素，可优化患者安全学习系统的设计。需要对患者安全学习系统的有效性进行评估，以完善其设计。
