Introducing incident reporting in primary care: A translation from safety science into medical practice

In this article, we examine how incident reporting procedures become part of the way primary health care professionals deal with safety problems. Between 2006 and 2010, we studied documents, observed incident reporting committee meetings and conducted formal and informal interviews in five Dutch primary health care centres and one general practitioner's out-of-hours service to describe the introduction of incident reporting procedures. In this article, we distinguish two approaches towards patient safety, the logic of risk management and the logic of medical practice. In the logic of risk management, safety is seen in terms of the prevention of recurrence of specific well-defined incidents. In the logic of medical practice, safety involves recognising uncertainties and strengthening implicit initiatives that underpin patient safety. Care providers alternated between the two logics and aligned them. Most reported incidents in primary care concern non-clinical incidents with no or limited impact on the patient. We observed that both physicians and medical assistants changed the significance of a particular incident by frequent reporting. By reporting apparently insignificant risks, those providing care were able to deal with these risks more explicitly and actively. The alignment of the two logics was different for clinical, more harmful incidents. Care providers rarely reported serious clinical incidents and we could find little evidence that they actively engaged with recommendations following the investigation of serious incidents. Both logics mutually shaped and informed each other. Incident reporting procedures made implicit initiatives explicit and the two logics ensure that safety involved multiple and different actions.