Closing the loop involves sharing what was learned from a systems analysis, both within an organization and beyond, in order to make care safer, prevent the recurrence of similar events, and promote trust and healing. This concluding step, which applies to both patient safety and incident management, offers a valuable opportunity for reflection and the identification of opportunities to further improve quality and safety outcomes as well as the systems and processes supporting them.
“Every time we take a patient safety incident, hazard through this reporting and learning cycle, we reduce risk, improve quality, and – more importantly – strengthen the patient safety culture which means that care becomes safer for patients.”-- Toolkit Faculty
This step can take as much, if not more, time than the analysis however, it is very important for learning, improvement and moving the patient safety culture forward. It is most successful when it is a regular process embedded within existing structures, includes established accountabilities and is aligned with local policies and legislation.
Share what was learned internally.
Share what was learned from the analysis with the patient/family, those involved in the incident, the person who reported it, senior management, the board, and others
Communicate results of recommended actions, taking care to respect patient/family preferences in terms of what they want to know and when
Engage with the patient/family in this process by asking if they would like to share their experiences with the organization and/or others
Communicate what has been implemented and the results, ensuring messages and channels are appropriate for each audience:
review the purpose of analysis, methodology and the findings as appropriate
share the factors that contributed to the incident, the defences that worked well, and what was learned about how to avoid similar incidents
review the recommended actions, their current status and their impact
maintain transparency and trust by being honest if plans have changed and share the reasons why
In accordance with organizational policies, use multiple mechanisms that transfer learning from the analysis between care units including memos, storytelling, huddles, team based peer review rounds, journal clubs, patient safety workshops using case based learning methods and newsletters
Maintain a record of communication to ensure all appropriate stakeholders have received the information
Recognize that sharing is a dialogue (not a one-way flow of information) and is ongoing (more than one time)
Encourage respectful, open communication around the results of the incident analysis at all levels of the organization
Share what was learned externally.
To prevent harm on a broader scale, disseminate what was learned externally through provincial, national and international reporting and learning systems in accordance with applicable legislation
Alerts, advisories and repositories can serve as vehicles for informing others about what happened, how and why, what actions were taken, and their impact
If appropriate, develop an external communication plan for informing the public about the actions taken, their impact, related relevant background and context, and include or exclude the patient/family perspective in accordance with their wishes
For public announcements, prepare the staff and the patient/family in advance discussing what information will be shared, when and how
Reflect and Improve.
Consider conducting a multi-incident analysis to better identify recurring system issues
Determine if what was learned can be applied to other processes in the organization
Communicate any noteworthy vulnerabilities and/or best practices through senior leadership or other appropriate body (e.g. quality committee, risk management, etc.)
Combine findings with those from different systems (e.g. accreditation, insurers, performance systems at a health system level) to help identify themes/patterns and accelerate learning
Assess the incident management process to identify strengths and opportunities for improvement, taking into consideration:
the timeliness of the analysis
the quality and effectiveness of the recommended actions
organizational guidance and supporting structures
communication and processes for sharing what was learned
the experience of those involved in the incident and the analysis
Support research and innovation focussed on learning from incidents