Incident Reporting, Just Culture and Open Disclosure [T-09-EN]

Incident Reporting, Just Culture and Open Disclosure [T-09-EN]

Underreporting of adverse events and near-misses remains one of the most consequential barriers to patient safety improvement globally. The WHO Global Patient Safety Report 2021 estimates that harm from unsafe care affects approximately 134 million patients annually in low- and middle-income country hospitals, yet the vast majority of contributing incidents go unrecorded and unanalysed. In Georgia and the broader South Caucasus region, accelerating accreditation to Joint Commission International (JCI) standards and alignment with European Union health system benchmarks have placed incident reporting and disclosure governance at the forefront of quality agendas. This course equips healthcare professionals with the conceptual foundations and practical competencies required to operate within a psychologically safe, accountability-driven reporting culture — converting individual error events into system-level learning.

The course is grounded in the evidence base established by the Institute of Medicine’s landmark report To Err is Human, the WHO Multi-Professional Patient Safety Curriculum Guide, and the principles of just culture as operationalised by Sidney Dekker and subsequently codified in JCI Accreditation Standards for Hospitals (8th edition) and ISO 45001 organisational safety management frameworks. Instructional design follows an active-learning model, combining structured case analysis of real sentinel events, facilitated ethical reasoning exercises, and scenario-based practice in disclosure communication — ensuring that participants develop transferable clinical judgement rather than rote procedural knowledge. International standards are applied throughout with explicit reference to Georgian national health legislation and the requirements of the National Center for Disease Control and Public Health of Georgia.

By the end of this course, participants will be able to:

• Distinguish between human error, at-risk behaviour, and reckless conduct using the just culture decision algorithm, and apply the appropriate institutional response to each category.
• Implement a structured incident reporting workflow — from initial detection through root-cause analysis — in alignment with WHO Minimal Information Model for Patient Safety Incident Reporting standards.
• Analyse a clinical adverse event using the London Protocol framework, identifying contributing system factors and generating evidence-informed recommendations for risk reduction.
• Construct an open disclosure communication plan for a serious patient safety incident, incorporating the four core elements of acknowledgement, factual explanation, apology where appropriate, and remediation steps.
• Evaluate an organisation’s existing reporting culture against just culture benchmarks, identifying structural and behavioural barriers that suppress voluntary error reporting by frontline staff.
• Demonstrate the communication skills required for a disclosure conversation with a patient and family, including responding to expressions of anger, grief, or requests for accountability, using evidence-based de-escalation and empathic engagement techniques.

Who Should Attend

This course is designed for all licensed healthcare professionals involved in direct patient care or clinical governance, including physicians, nurses, midwives, pharmacists, and allied health practitioners working in hospital, ambulatory, and emergency care settings. It is of particular relevance to patient safety officers, quality coordinators, department heads, and senior nurses responsible for managing incident investigations and disclosure processes at the institutional level. Mid-career clinicians transitioning into leadership or supervisory roles — and facilities preparing for JCI or national accreditation review — will derive immediate and measurable benefit from this programme.

Course Structure

This self-paced online course comprises four structured modules with an estimated completion time of six to eight hours, including embedded video case studies, reflective exercises, and a final scenario-based assessment requiring a minimum score of 75% for certification. Successful completion awards CME/CPD credits in accordance with GMJ Academy’s accreditation framework, with a certificate of completion recognised for professional development portfolios under Georgian Medical Council continuing education requirements.