Visualizing learning from patient safety incidents to promote a blame-free culture: a case study from Al Dhafra Hospitals (QUALITY IMPROVEMENT PROJECT/CARE DELIVERY AND PRACTICE DEVELOPMENT REPORT)

Visualizing learning from patient safety incidents to promote a blame-free culture: a case study from Al Dhafra Hospitals (QUALITY IMPROVEMENT PROJECT/CARE DELIVERY AND PRACTICE DEVELOPMENT REPORT)

quality improvement, Incident reporting, novel method, risk management, culture of reporting

Hospitals worldwide encounter significant challenges in enhancing and maintaining effective incident reporting systems. A fundamental aspect
of this improvement is fostering the right culture, which facilitates reporting and learning. In this case study, we describe an approach for incident
reporting improvement at Al Dhafra Hospitals, SEHA, through the conceptualization of a “garden of improvement.” The garden provides a visualization of key learning emergent from reported safety incidents to signal to staff the value and importance of their contributions to improving
patient safety. To address the barriers to effective incident reporting, we employed three key components: a self-reflection tracking sheet, a visual
depiction of the Garden of Improvement, and a reward system. We observed a 17% increase in incident reporting, including a significant jump in
near-miss reporting. The proportion of good catch reports also more than doubled, from 3.0% to 6.9%. The implementation of this model has
supported interdepartmental collaboration, knowledge sharing, and continuous improvement.

Shaik Mohiuddin, Isam Elhag, Shamsa Mubarak Almansoori

DOI:https://doi.org/10.1093/ijcoms/lyaf011

Oxford University Press

25 September 2025

Sri Wahyuni

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