Patient safety reporting systems: A literature review of international practice

To inform a scheduled review of the National Reportable Events Policy, the health Quality & Safety Commission has conducted a brief scan of overseas literature on patient safety reporting systems. This report summaries the literature review findings.

This report provides the context for findings on best-practice and overseas approaches by giving a brief history of PSRS (Section 3), summarising key challenges facing PSRS (Section 4) and key features of successful PSRS (Section 5), and giving an overview of the role of national PSRS (Section 6). Detailed outlines of best-practice approaches for local and national PSRS follow, including brief commentary on approaches in overseas jurisdictions (Sections 7 and 8). In the final sections, the report briefly re-visits some of the key questions about PSRS (Section 9), highlights emerging thinking on patient safety and its management (Section 10) and draws together the key messages from the literature (Section 11). It is expected that findings on best practice for local PSRS, and emerging thinking on the role of PSRS, will interest those involved with patient safety reporting in district health boards and other health care organisations.

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The overall objective of the literature scan was to describe best and emerging practices for PSRS, including approaches in overseas jurisdictions.


Finding relevant published literature involved searching four large databases: Ovid MEDLINE (R), Embase, Scopus and the Cochrane Library. For unpublished literature, the process was to use specialised Google searching and grey literature search engines (for example,, as well as to review the websites of relevant non-governmental, government and think tank organisations. Search terms such as ‘incident reporting’, ‘reporting and learning system’, ‘safety reporting system’, ‘organisational learning’, ‘near miss’ and ‘adverse event’ were used separately and in combination. Where articles gained through these methods made other relevant citations, those citations were also sourced.

The literature search included published and unpublished (‘grey’) English language literature written since 2013.

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