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  1. Espin, Sherry PhD, RN
  2. D'Arpino, Maryanne MScN, CHE, RN, CHE
  3. Indar, Alyssa MN, RN
  4. Gross, Marketa MN, RN


Background: Nearly 10% of patients experience a harmful patient safety incident in the hospital setting. Current evidence focuses on incident reporting, whereas little is known about how incidents are managed within organizations.


Purpose: The aim of this study was to explore processes, tools, and resources for incident management in Canadian health care organizations.


Methods: Qualitative focus groups were conducted with key stakeholders, representing clinicians, managers, executives, governors, patients, and families (n = 45).


Results: Qualitative data were thematically analyzed and presented as 3 themes: (1) variations in incident reporting and management; (2) simplification of the incident management process; and (3) need for leadership to support just culture and redefine harm.


Conclusion: The study findings support and inform efforts to create a patient safety culture in Canadian and international health care organizations. There is a need to develop a standardized, accessible incident reporting and management system for use across health care sectors to promote continuous learning and improvement about patient safety.