A Multi-Stakeholder Survey Examining Incident Review Processes in a National Healthcare System: A Study Protocol

Abstract

Background Incident reporting is central to patient safety, yet translating review findings into systemic learning remains challenging. Within the Irish Health Service Executive (HSE) 2020 Incident Management Framework (IMF), Improvement Planning and Monitoring (Step 6) is where findings are intended to become service change. How well reviews achieve this, and how the review methodologies in use shape that performance, has not been systematically examined. This protocol sets out a study examining how these methodologies operate in practice and the perceived quality of the recommendations they produce, by capturing the accounts of multiple stakeholders linked to the same reviews, with particular attention to human factors in the transition from learning to action. Methods The study uses a cross-sectional, mixed-methods survey design. A stratified random sample of 96 incident reviews will be drawn from the National Incident Management System (NIMS): 48 Category 1 (major/severe harm) and 48 Category 2 (moderate harm), equally divided between acute and community settings. Seven role-tailored instruments, mapped to four stakeholder categories (reviewers and commissioners; clinical staff; implementers; patients, service users and families), combine rating-scale and written-response questions organised around the six IMF principles. Quantitative data will be analysed using descriptive and non-parametric methods, qualitative data using reflexive thematic analysis, and the two strands integrated through joint displays. Ethics and dissemination Ethical approval has been granted by the School of Psychology Research Ethics Committee at Trinity College Dublin and the HSE National Research Ethics Committee. A pilot phase of five reviews will precede national administration. Findings will be disseminated through peer-reviewed publication, conference presentation, and a summary report to the HSE, and are intended to identify systemic barriers to improvement planning and inform a national logic model for shared learning.

The authors' abstract, as published at the source. HRB Open Research, 2026 · DOI ↗