Once participants completed informed written consent, they completed an electronic demographic and attitudinal survey about PSI responses and management (via Redcap, web-based software methodology tool for designing clinical, translational and quality improvement databases: https://project-redcap.org/). Development of survey questions was informed by literature across implementation science (78, 79) and safety science (45, 80–89) domains, as well as team expertise. This survey collected participant demographic details and attitudes towards the patient safety response and review process on a 5-point Likert scale.

After the survey was completed, focus groups and individual interviews were conducted via Microsoft Teams or Zoom software or over the phone following a predefined topic schedule (See Supplementary File S3), recorded and transcribed verbatim. Interviews and focus groups were conducted by researchers (PH (professor; male), MB (PhD, Research fellow; female) and YY (PhD, Research fellow; female)) who are experienced interviewers and health service qualitative researchers. Two of the interviewers (MB and YY) had no prior relationship with the interviewees prior to data collection, however, the lead investigator PH had prior professional relationships with several interviewees, but did not coerce participation. Participants were not reimbursed for their time.

Participants indicated that all reported PSIs are assessed in one form or another, depending on the severity and outcome of the incident, to learn from and prevent recurrence. However, the depth in which they are reviewed is variable. Imminent risk is reviewed, and strategies put in place to prevent the incident from reoccurring in the short term. Participants discussed how the PSI review process is typically guided by triage using the incident harm score, as to whether the incident requires in-depth investigation or a more rapid review. The treating clinician or nurse reports the incident, within incident management software, and the severity score is assessed and verified. Participants noted that there was often misunderstanding of the criteria for different harm scores by the reporting clinician, resulting in more incidents being categorised as having a more severe harm score than necessary. Participants also noted potential for conflict of interest when line managers verify harm scores. They explained that incidents, initially rated as severe or serious (e.g., with a SAC, ISR or Harm Score 1 or 2), are typically triaged by an executive director, reviewed and finalised by an executive committee, and that harm scores are commonly revised to a lower harm level. Participants described how committee meetings may discuss a range of incident types with different severity levels. In addition to validating the harm score, they decide which methodology will be utilised to investigate the incident and assign review team members to conduct the review. It was highlighted that this executive review can be delayed, however, if executive staff are time poor.

Participants detailed how lower severity incidents may be reviewed by a Morbidity and Mortality review team (M & M) meeting, or a local line manager, discussed at Grand Rounds, or reviewed via a desk top review by the quality and safety team or a local ward/department clinical manager. These incidents are typically reviewed through a rapid review methodology or not at all in any meaningful way. If there is significant opportunity to learn from the incident, then an executive team may commission the patient safety team to lead a more in-depth review. Consideration may also be given to potential for harm, particularly in near miss events.

Participants explained how across different jurisdictions, policies dictate whether incidents with high harm scores are mandated to be reviewed using specific in-depth review methodologies [such as a Serious Adverse Event Review (SAER) for harm score 1 incidents in NSW] (17). They noted that this process may not specifically consider whether a comprehensive review would provide opportunities to learn from the incident. When not bound by such legislation or policy, the opportunity for learning from the incident is often considered to select the most appropriate review methodology.

Participants reported that serious incidents including those resulting in death or permanent harm make up a small proportion of incidents that occur annually but consume the vast majority of resources to conduct in-depth reviews (often in response to legislation) that tend to be reactive, case specific and focused on behaviour. They identified that this limits the opportunities and resources to review and learn from lower harm incidents, and near misses through proactive and preventative improvement work that aligns with a systems-thinking approach. For certain incident types, such as falls, or when a system wide issue is identified (similar events occurring across a hospital), participants explained that a rapid or thematic review may be conducted. Compared to an in-depth review, many felt that this rapid review option has the benefit of releasing resources for other in-depth investigations of serious harm events, or lower harm events and near misses, as well as the implementation of review recommendations.

Participants discussed how they utilise various investigation methods during PSI reviews. Commonly described methodologies included Root Cause Analysis (RCA), the London Protocol, Human Error and Patient Safety framework (HEAPS), Root Cause Analysis and Action (RCA2), Concise and comprehensive reviews, and the Accident Mapping Approach (AcciMap), as well as methods such as audit and feedback, cause and effect analysis (Fish bone diagrams or Ishikawa analysis), Five Whys analysis, and more rapid processes of review by Morbidity and Mortality teams using a template. In our study, RCA and RCA2 remain the dominant method in many Australian states and territories. The international participants also reported using Functional Resonance Analysis Method (FRAM), Systems Theoretic Accident Modelling and Processes (STAMP), Hierarchical Task Analysis (HTA), Systems Engineering Initiative for Patient Safety (SEIPS), The Patient Safety Incident Response Framework (PSIRF), as well as the Yorkshire contributory factors framework and the Learning Review Methodology (See Box 2).

There was no consistent methodology reported to work well across different incidents. RCAs were perceived by participants to have limited effectiveness, learning opportunities and capacity to share findings, and incidents reviewed by RCA (typically high severity) were often protected by legal privilege legislation. Thematic reviews of high frequency and similar events that occur across a hospital were perceived to achieve change in practice and patient outcomes and seen as helpful tools to analyse commonly reoccurring incidents from a systems perspective.

A small number of participants described conducting thematic reviews themselves, with some noting that if a patient's family wanted individual findings and action, then an individual comprehensive review was typically conducted. Participants however felt that individual reviews often did not effectively capture contextual data around the incident. They noted that reviews in Australia tend not to undertake secondary observations of standard clinical practice and tend to rely on interviews and medical records as their key data sources, whereas in the UK, observations have become a well-regarded source of data to inform incident reviews.

Participants described how PSI review teams may be commissioned by a senior executive such as the Chief Executive Officer, or an executive triage team. Establishing an investigation team was seen as a fundamental step in the PSI review process as it requires careful planning for balance of clinical specialty subject matter expertise, experience and independence, and is time consuming. Getting buy-in from busy, senior clinicians, nurses and heads of units was identified as challenging with operational demands given precedence. Participants described how the ideal PSI team would include independent experts external to the organisation, but that recruitment is reportedly variable and challenging for those roles. Participants felt that independent panel members can bring expertise around systems thinking and human factors, dedicated focus, and encourage accountability and professionalism.

Participants also highlighted that proxy representation of the individual staff involved in the event (staff in similar roles with similar levels of experience) may also be included in the review team. While engaging with and interviewing individual staff directly involved in the incident provides valuable insight into what occurred, concern was noted that their perspective may bias a review, by reducing objectivity, and thus their inclusion on the review panel should be avoided. Participants felt that the chair of the PSI review panel should have human factors knowledge and systems-thinking experience, as well as clinical expertise relevant to the incident, without having been directly involved, as they play an important role to facilitate input from panel members in a non-hierarchical manner. Support by administration staff was also perceived to be beneficial for reviews teams, to reduce the logistical and organisational burden involved with conducting an incident review.

To be a skilled investigator, participants felt that individuals need clinical knowledge, expertise in systems thinking and human factors as well as a strong understanding of investigation methodologies and general principles. Review team members, however, were often perceived to lack experience and knowledge of those paradigms. Training and experience of review team members was reportedly variable across jurisdictions, partly influenced by high staff turnover, and limited training resources and courses available. Participants noted that inexperienced team members need additional training and support to conduct reviews and produce high quality reports with Specific, Measurable, Achievable, Relevant and Time-bound (SMART) recommendations. They described the same challenges for inexperienced quality and safety staff who require on the job training, adding to the workload of quality and safety teams. Staff working in higher volume metropolitan hospitals were perceived to have greater incident review experience, compared to lower volume rural and remote sites. More broadly, participants stated that review team members need capacity to conduct reviews, but that this is impacted by high workloads and limited time. Participants also noted staff burnout and frustration that despite effort and emotional investment during the review process, changes to care often do not eventuate.

Safety and Quality and Clinical Governance staff were perceived to provide expert guidance, facilitate reviews for serious harm incidents, and provide support and resources for lower harm incidents. They are also perceived to support the review team once the report is drafted, enabling refinement of recommendations, and providing insight regarding similar concurrent improvements projects to avoid duplication of work and share findings. While safety and quality staff are typically skilled clinically, participants expressed concern that they are not always remunerated in parallel to more high-paying clinical roles, and this in combination with the workload and emotional impact of the job, may contribute to high staff turnover. Participants noted that this high staff turnover in turn translates to constant training of new staff. Safety and Quality and Clinical Governance roles were perceived to have become siloed in some jurisdictions, limiting opportunity to learn from and collaborate with each other. Participants noted that a strong community of practice is needed, but not always available, to support and facilitate collaboration across (siloed) quality and safety teams.

Depending on the jurisdiction, participants reported that some review panels include consumer representatives (CRs), particularly in Victoria where it has been encouraged in policy. Participants generally considered CRs to be a valuable addition to the team, bringing a different perspective to the review. However, participants noted that CR involvement requires careful facilitation, executive support and training both for the CR, and the review panel. Participants described how effective engagement with CRs requires facilitation by the review panel Chair to ensure the wellbeing and psychological safety of the CR and the panel staff. Consumer input was considered useful by participants, even if the consumer is not directly on the review panel, with consumer review of reports and findings to be helpful.

Engagement with, and seeking input and feedback from, patients and family members about the PSI and review process was reportedly variable, but valued, adding depth to the review if facilitated sensitively and supported through staff training. Participants described how this may be conducted by a dedicated family contact (DFC, in New South Wales for serious incidents), a liaison staff member dedicated to support families, or a social worker, who aim to engage with patients and families, support them throughout the review process, and act as a point of contact. Participants noted that DFCs should also provide additional information around the review progress, findings and actions, as well as linking families to additional support services. However, this is variable across jurisdictions and was identified as an area for improvement.

Clinician disclosure to patients and families is conducted by the treating clinician, typically shortly after the incident. Participants noted how important this step is, but how variable the quality of the disclosure can be, influenced by the level of staff experience, training and confidence, as well as the organisational culture around clinician disclosure being conducted after an incident. Participants described how open disclosure, a process which includes an apology, is then conducted by independent staff members, such as quality and safety or executive clinical directors, typically before the review process begins. This process is embedded in the mandated Victorian Statutory Duty of Candour process, which participants noted has improved engagement with consumers. It was noted that patients and families may then be provided with a second open disclosure process about the review and findings, once complete.

The key purpose of a PSI review is to identify what went wrong, to learn from the incident and to prevent reoccurrences by identifying and implementing recommendations. Consulting with staff who were involved in the incident, as well as those likely to be affected by the recommendations including medical directors with oversight of staff and teams, was deemed useful, but variable in practice. Clinical engagement during the PSI review process was identified as a key challenge, when medical staff are reluctant to participate in the review process. Participants posited that this may be related to the Visiting Medical Officer (VMO) model, particularly in rural and regional areas, where clinicians are appointed to teams for short periods of time and therefore are not well integrated into the local system.

Consulting with the teams directly involved in the incident, and those who will be impacted by the recommendations was considered important, to capture their perspectives, and to support them after the incident, particularly when staff distress is identified. Participants felt that engagement with staff directly involved in the incident [acknowledging the second victim experience (95, 96)], needs to be managed carefully however, as the process of review can add to their trauma. Consulting with safety and quality or consumer engagement staff who are not directly involved in the review, was also identified as a useful quality check process to ensure rigour in the review process and findings.

Team hierarchy was perceived to influence the recognition of some review team members, influencing their input into report findings. Another challenge noted by participants was the introduction of new incident management or Electronic Medical Record (EMR) systems. According to participants, if staff do not know how to navigate new systems well, information may not be captured adequately, impacting the quality of analysis in the review.

In terms of engagement with patients and families while conducting the review and developing recommendations, participants reported variation in the formal processes used to hear the patient perspective, and what they want the review to achieve, as well as how this is considered and documented within the review report. This was identified as an area for improvement by most participants. Participants raised concerns about patient and family vulnerability and how this perception can lead to their exclusion from participation in reviews, though this remains a subject of ongoing discussion.

Participants posited that effective recommendations reflect a thoughtful and in-depth analysis of the contributing factors, address system and process change and clearly link to appropriate implementation strategies. Developing meaningful, concise, clear, and effective recommendations that are measurable, achievable and implementable, was identified as a challenging, time consuming, resource intensive process, requiring skill and engagement with large clinical teams. Participants felt that following SMART (Specific, Measurable, Achievable, Realistic and Timely) principles can support the development of quality recommendations. Consulting with past reviews of incidents (both locally, intra-state and nationally) was also considered to be helpful in learning about effective recommendations. However, this can be challenging as it relies on individual networking, with no current infrastructure available, or secure permission system, to search for such information easily.

Participants described how clinician workloads and lack of time to conduct the review and formulate recommendations can limit the quality of outputs. Participants also noted it was challenging to get busy clinicians to engage in review training to further develop skills. Development of recommendations by team members without relevant clinical experience or without consultation with relevant clinical staff was perceived to impact the applicability of recommendations. This was noted as a particular issue in rural settings, when external but non-rural clinicians may develop recommendations without contextual understanding of the setting, limiting the applicability of their recommendations.

Participants noted a tendency to develop weak and ineffective recommendations and attributed this to the fact that recommendations are an expected review component, and team members feel compelled to make recommendations. They felt that the resulting large volume of weak, standard, “go to” recommendations (such as to change a policy or educate a staff member or specified group) have resource implications by detracting resources from the implementation of higher quality recommendations. Participants described how clinicians may lack implementation science training/expertise limiting their use of evidence-based recommendations and behaviour change techniques. Participants noted that there are efforts in some jurisdictions to minimise the number of recommendations and ensure final recommendations are concise and strong.

Participants explained how incident analysis reports and recommendations are typically reviewed at various executive levels, modified as appropriate, finalised, endorsed by a general manager or clinical director, and signed off by a senior executive. Support and engagement with quality and safety teams, executives and leadership prior to formal sign off meetings was seen to support quality recommendation development. This process was also seen to help refine and strengthen recommendations, to ensure they are effective and sustainable, provide expert but independent advice and alert teams to similar recommendations or improvement work implemented elsewhere within the organisation, and to minimise the timeframe for signoff by executive.

On the other hand, participants noted that recommendations may be amended and weakened at the executive endorsement and sign off stage. This ‘sense of learned powerlessness’ was a common challenge discussed [a term that originates from the psychological phenomenon of learned helplessness (97)], when an issue and solution is identified, but no corresponding recommendation is made in the final report because system and resource-intensive recommendations are often seen as unfeasible, unrealistic, or unlikely to be approved by executives. Participants felt that they had limited authority to recommend meaningful changes. Participants reported that PSI review reports and findings are often influenced and modified by executives who are conscious of political or media pressure, as well as concern about reputational damage, or that certain recommendations could be interpreted as criticising health service organisations. They felt that such reactive responses to political and social influences can influence review processes, result in weaker recommendations and undermine the aim of the process. For example:

There was large variation noted as to whether review reports (or their drafts) are provided to patients and families, or findings simply summarised, with participants reporting that some organisations only provide reports to families following a Freedom of Information request, while others share both the draft and final reports. Participants noted that reports about higher severity incidents were often shared with families, however, reports or summaries of findings for lower severity incidents are typically not shared. Participants felt that sharing the draft report with families provides an opportunity to gather their perspective and input on the findings and recommendations, and the inclusion of a plain language summary can be beneficial. Several participants noted that often reports are not well received by families, as they inadequately capture the family's experience and trauma. Consideration of the benefit or impact of an incident review for patients and families, as well as staff wellbeing, was also considered important.

Participants described how report findings and recommendations are uploaded into an incident management system and a timeframe is set for implementation based on the KPIs and policy of each jurisdiction. The implementation process may then be tracked and monitored through that system by safety and quality teams who are typically not tasked with responsibility for implementation, however participant responses suggest this is variable. Participants explained that in some jurisdictions, quality coordinators coordinate with clinical business units to facilitate the implementation of recommendations, document and monitor the process, and provide evidence back to the units. They noted that recommendation implementation may be monitored by executive committees and safety and quality teams, reporting on the progress and completion as appropriate. Participants reported this process to be variable in Australia and internationally with poor monitoring negatively impacting on effective implementation, sustainment and achievement of change. They posited that this may be as the development of recommendations and their implementation may be tasked to different siloed teams, limiting follow through and accountability. Participants were enthusiastic about the benefits of recommendation registers to support the tracking and monitoring of the implementation of recommendations, particularly when accountability was tasked to a position, rather than an individual, to account for staff turnover. Assigning recommendations and their implementation to appropriate senior staff who are responsible for the achievement of change, and who can delegate the process, was considered an important facilitator to this process. However, this was also noted as challenging when recommendations relate to multiple areas in the health service as opposed to a single ward.

When implementation of a recommendation is monitored, participants highlighted that evaluation to ensure fidelity (implementation as intended) and assessment of the quality of outcomes is variable. Quality monitoring and evaluation were considered important to establish evidence regarding strategies that successfully impact care and patient outcomes to garner support for sustainability and scale up of the change, or to apply improvement strategies to other areas. Dashboards tracking recommendation implementation, regular meetings, and biannual reports were perceived as ensuring accountability and support implementation:

According to participants, the implementation of recommendations associated with serious incidents tends to be tracked; however, this is often not the case for lower harm incidents. Participants noted the high frequency of particular incidents reoccurring, resulting in similar review recommendations being developed but not effecting change, and how this indicates a need to enhance the quality of recommendations and their implementation. Implementation was perceived to have fewer resources and time allocated, in comparison to the review process. Participants noted that this results in recommendations and their implementation not achieving intended changes to care practices and patient outcomes. Similarly, participants reported that it can be challenging when funding dedicated to implementing a specific recommendation ends.

Participants explained that nurses in leadership roles (for example, Clinical Nurse Consultants and Nurse Unit Managers) or clinicians, are often tasked to implement recommendations in their teams, or areas, despite not always being familiar with the context, incident or contributory factors underpinning the recommendation. Hierarchies and power dynamics across teams were perceived to make it challenging to establish clinician buy-in with the implementation of recommendations, with both issues challenging engagement and the potential to influence change across a hospital. Greater collaboration and interdivisional agreement on implementation action plans was perceived to improve buy-in and holistic understanding of the drivers of change. Participants reported that high staff turnover also leads to loss of institutional knowledge and understanding of the review underpinning the recommendations, impacting the implementation of recommendations. While recommendations and implementation plans may be documented within the original reporting software, long-term monitoring of the implementation of the recommendation, and outcomes achieved was reported to be variable, particularly after the implementation process has been signed off.

Frustration was reported that recommendations and their implementation strategies get modified through various bureaucratic processes. Final implementation plans were often perceived to differ to what was intended by the review team, limiting the accountability for effective implementation. Staff turnover at the management or executive level was seen to contribute to this, leading to limited accountability when implementation is person specific, rather than role specific. Participants felt that management and executive role-accountability supported implementation and facilitated change. Participants also highlighted a tension between being reactive to an incident while also providing enough time for a quality review and implementation process. Timely but effective implementation of recommendations was considered fundamental, to ensure those involved feel confident they can enact change.

Weak recommendations that are not specific or measurable, were seen to be challenging to follow up and implement, making implementation an ineffective tick box exercise that rarely achieves the intended change to care practice or patient outcomes. However, participants reported that even strong recommendations may be poorly implemented with limited support and expertise to guide the process. Despite the weak nature and limited evidence for education alone as a behaviour change strategy, participants described how education-based recommendations are often recommended. This is in favour of more challenging systems thinking-based recommendations. Participants felt that system-wide changes are particularly difficult to implement, as they involve cooperation and coordination of multiple interdivisional and inter-organisational stakeholders, particularly in jurisdictions with devolved health services. They were also perceived to be more resource intensive, and therefore not always perceived as feasible. Participants noted limited shared learning about recommendations and implementation strategies that have been effective elsewhere. Participants noted that access to this information would be useful to support the development of more robust implementation plans. Providing patients and families with updates on the progress of implementation, sometimes as a part of the open disclosure process, was also variable, as staff felt some families were not ready to engage in the process, whereas others were keen to be updated.

Participants reported that there were generally clear, mandated review, governance and accountability processes to follow for incidents. They held that regular quality and safety meetings provide support to collaborate, and monitor, conduct preliminary assessments, assess the review criteria thresholds to determine the required methodologies for incident reviews, and support open disclosure and implementation of recommendations processes.

A commonly reported challenge for participants was the strict timeframes and associated Key Performance Indicators for the PSI review process to be initiated and completed within. Participants noted in QLD, for example, reviews of PSIs with a Severity Assessment Code 1 (SAC1) [equivalent to Harm score 1 in NSW, or Incident Severity Rating (ISR) in Vic] must be completed within 90 days. These timeframes were described as being unfeasible for overworked staff, particularly for complex incidents involving multiple clinical specialties requiring enormous coordination and engaging with an often part-time workforce. Resourcing challenges were discussed regarding a lack of staff and time, challenging and delaying the completion of reviews and findings. On the other hand, deadlines were also perceived to keep participants accountable. Adding to these challenges, the reporting management systems commonly used were not considered to be user friendly.

The value of undertaking individual reviews for certain incident types (such as falls) was queried, with participants expressing frustration at the resource intensive comprehensive review process that often results in limited learning. Participants explained that policies to assess the need for a comprehensive review lacked flexibility, leading to duplication of work through individual reviews of similar events, without learning from previous reviews, suggesting in some circumstances cluster/thematic reviews may provide greater value.

Similar to local organisations, participants reported limited sharing of learnings across health services, with siloed services and clinicians unaware of incident reviews and implementation strategies conducted elsewhere, and limited opportunities to learn from exemplar reports from inter and intra-state. Participants noted that certain jurisdictions are also bound by Qualified Privilege or Statutory Immunity legislation, which limits the capacity to share findings. Some participants reported limited comparative feedback from statewide or national departments of health about the quality of the review report and findings, limiting staff opportunities for learning,

Participants indicated that leadership style influences the incident review process and culture around reporting. Transparent and collaborative leaders, with dual governance or safety based leadership and clinical roles support the culture of reporting PSIs, as well as systems thinking, while minimising blame and focusing on opportunities to learn from incidents and near misses. Executive support was considered important, providing broad oversight of the incident review process and guidance through legislative requirements, supporting communication with families, and endorsing review reports. However, participants also felt that executives were cautious of political influences, and wary of identifying contributory factors to an incident in a review that could be interpreted as criticisms of health departments. Similarly, participants identified that executives may amend final recommendations that have an operational impact and require resourcing for improvements, resulting in weaker recommendations.

A robust governance and accountability system was seen as a key strength to support the development, implementation and evaluation of evidence-based recommendations that are likely to be effective and sustainable. International experts identified this as an area to focus improvement efforts on, to enhance reporting, analysis and accountability, and reduce the siloed nature of services.

An open, transparent and restorative just culture with a systems thinking focus was touted as a fundamental element to patient safety, to encourage reporting with timely feedback. A positive reporting culture was perceived to be improving across Australia and internationally, albeit slowly, encouraging staff to be open about incidents, but needs continuing investment to develop further. Participants noted that improvements to this culture can be hindered by staff turnover. Resistance to incident reporting remains a challenge, with participants noting under reporting or insufficient escalation of incidents, partly a result of staff not understanding the escalation and governance processes.

Participants highlighted the importance of listening to consumer voices was as component of a just and learning-oriented reporting culture. From their perspective, meaningful involvement of consumers and their families in the review processes should be carefully supported and embedded, not as a procedural task, but as an ethical commitment. Several participants acknowledged that complexities involved, including the vulnerability of those affected. Similarly, ensuring that clinician disclosure is conducted consistently, and that clinicians are well trained and consistently supported to conduct disclosure. was identified as another important improvement that needs to be embedded within the review process. Some participants noted that while strengthening a strong culture of reporting is important, if not managed carefully, it may also increase the workload of quality, safety and improvement teams.

Participants discussed how many health services still face the challenge of overcoming a blame culture, embedded from the executive level down, and strive to ensure that the restorative justice message is consistent at all levels of the organisation. Poor and inconsistent communication, a lack of transparency and prevailing blame language were perceived to counteract efforts to bring about organisational cultural change, and efforts are required to address misconceptions staff hold about punitive consequences of reporting incidents. This is particularly challenging when staff are overworked.

Participants felt that some individuals and organisations harbor concerns about reputational damage resulting from PSI reviews. A lack of psychological wellbeing support for staff conducting the reviews or involved in the incident was also noted. In some cases, the trauma of the incident, and the review process, was reported to result in staff leaving their positions, losing valuable human and organisational knowledge in the process.

This lingering blame culture was seen to result in limited opportunities for shared learning from incidents, and near misses. Participants noted that learning can be further limited by the siloed nature of health services and teams leading to duplication of improvement work, with poor dissemination of findings from reports or thematic summaries of incidents, and limited sharing across teams, organisations, and health systems. Participants also felt that sharing can also be hindered by confusion around Qualified Privilege or Statutory Immunity legislation (98) and the limitations that it places on data sharing. Participants noted that findings from reviews are often not shared with the staff who reported the incident, which may discourage staff from reporting future incidents if they feel nothing was actioned by their report. Similarly, quality and safety teams may share findings from reviews, or thematic analyses with executive or senior staff, however participants noted that this information may not reach the clinicians on the ground who may be impacted by the implemented recommendations, nor the reporting clinician or clinicians who were directly involved in the original incident.