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Incident reporting and learning systems for chiropractors--developments in Europe.

Providing health care of any kind, including the provision of chiropractic treatment, can be a complex and, at times, risky activity. Safety in healthcare cannot be guaranteed; it can only be improved. (1) The capturing and recording of information on patient safety incidents, and analysing this information are essential steps to reduce and manage risk and ultimately improve patient safety. With this in mind the first chiropractic incident reporting systems within Europe started to be developed in England and Switzerland, and both countries have now established national online reporting systems. Furthermore, under the auspices of the European Chiropractors Union, work is currently underway to finalise European guidelines for chiropractic incident reporting and learning systems.

Early efforts linked to the management of clinical risks within the healthcare professions, including chiropractic, were primarily related to the setting up of processes in an attempt to control litigation and to reduce associated costs. Due to the increasing move in the late twentieth century towards documenting and learning from patient safety incidents, individuals within the chiropractic profession in Europe also realised that it was paramount to become part of this developing safety culture.

The UK Chiropractic Patient Incident Reporting and Learning System

In 2005, the Anglo-European College of Chiropractic (AECC), in conjunction with the British Chiropractic Association (BCA), introduced the 'Chiropractic Reporting and Learning System' (CRLS) to collect patient safety incident data from BCA members. (2) It was taken up by the student clinics at AECC and, in modified form, at the Welsh Institute of Chiropractic and was subsequently rolled out to members of the Scottish Chiropractic Association. Although available to approximately 1600 of the UK's chiropractors, the initial take-up had been low. (3) Lack of awareness of the system and the types of incident that should be reported, as well as fear and confusion regarding anonymity and the medico-legal implications of submitting reports, were identified as key in explaining this underutilisation. (2) A second system known as the Patient Incident Reporting and Learning System (PIRLS) was developed at the McTimoney College of Chiropractic during 2007.4 PIRLS was launched by the McTimoney Chiropractic Association ensuring incident reporting was available to a further 600 UK chiropractors.

In order to unify the process of safety incident reporting in the UK and to facilitate participation among all 2500 UK chiropractors, the College of Chiropractors, the three UK chiropractic educational institutions, and the four UK professional associations combined their experiences in a joint project to develop a new online reporting system known as the Chiropractic Patient Incident Reporting and Learning System (CPiRLS). The CPiRLS project aims to enhance the learning element and improve the ease and accessibility of incident reporting, to help educate chiropractors about the types of incidents they should report and to reassure chiropractors that the administration of incident reporting is independent, secure and anonymous such that they have nothing to fear by sharing their experiences. The project forms part of a wider initiative to further enhance the culture of safety within the UK chiropractic profession.

The CPiRLS website ( informs all visitors of the purpose and nature of incident reporting and learning but, in its initial form, is set up such that only UK registered chiropractors can submit and read reports. This is ensured through secure access with a universal password available only to chiropractors via the membership areas of their association websites. The universal nature of the password and design of the website database mean that individuals submitting reports cannot be identified by anybody, including those administering the system. This was felt to be essential if chiropractors are to feel comfortable and secure in submitting and sharing reports without fear of legal retribution. (5)

The CPiRLS online reporting form is provided in three versions according to whether the incident under report has either happened, nearly happened (near miss) or has been identified as an incident waiting to happen (following identification of an error or discrepancy of process for example). Users start by choosing between these three types of incident and then progress through the form explaining what happened, why it happened and what actions were taken. Drop-down lists and radio buttons assist simple and rapid completion of the form.

Submitted reports are published in outline form on the website. Users who are logged in to the site can read these reports and submit comments. This sharing of information and interaction among peers is designed to maximise the learning aspect of CPiRLS. All submitted material is monitored by CPiRLS team members who can edit inappropriate matter and access/download all data for future thematic analysis.

The CPiRLS initiative is actively addressing the current underutilisation of incident reporting as a learning tool and has lead to the publication, by the CPiRLS team, of alerts and detailed guidance to assist chiropractors in managing risk more effectively.

The Swiss Chiropractic Reporting and Learning System

It is primarily legislation (Swiss Sickness and Accident Insurance and the Swiss Law on Medical Professions) that drives quality management for patient safety in chiropractic practice in Switzerland. The increasing awareness and political commitment to improve safety affects all health care sectors--including the chiropractic profession. The need for health professionals to continually improve quality and enhance patient safety is omnipresent. Unfortunately, the majority of well developed critical incidents reporting systems are implemented in clinical inpatient and hospital settings, almost none of them in private medical or chiropractic practices. These facts and the low reporting rate cited in the UK study conducted by Thiel and Bolton (2006) (2) encouraged the Swiss Chiropractic Association to further investigate chiropractic incident reporting, its promotion and implementation. A first reporting and learning project--Swiss Critical Reporting and Learning System (CRLS) was launched in September 2007 by Wangler and Zaugg. (6)

Regular patient safety training is not yet established in chiropractic. In order to promote a change in attitudes towards greater patient safety, information and education should be part of the training of future chiropractors. With the help of a literature synthesis, (7) Bland et al.'s 10 factors (8) were adapted for a successful promotion of patient safety competence in private practice, i.e. reporting and learning form adverse events in chiropractic care. The annual Swiss National Continuing Education Convention 2007 was considered to be the ideal environment to introduce and promote this first reporting and learning project. A survey on chiropractors' readiness and capacity for patient safety attitude change--using the Safety Attitude Questionnaire (SAQ) (9,10) for ambulatory care--was conducted to assess the competencies of Swiss chiropractors in relation to patient safety issues. The project consisted of four instructional approaches: written documentation, lecturing including a short movie, large and small group discussions on patient safety and safety culture, and feedback by experts. Qualitative analysis showed the following results: (6)

(A) The biggest challenge seemed to be the culture shift from blame to trust, from covering up to disclosure.

(B) Lecturing is inexpensive and convenient, but did not change behaviour in practice. As with clinical reasoning, reporting cannot occur in a vacuum--but must be built into the daily practice.

(C) Reporting and learning have first to be judged as an important skill to be developed and practised.

(D) An interactive forum on a password-protected website to discuss real life adverse events driven by discussion between experts and practitioners could be used to help in developing such a skill.

(E) A strong statement from leaders of the organisation i.e., "all its members have a responsibility towards reporting and learning" was missing.

(F) Safety and quality have to be integrated into training on a regular basis as well as into continuing education programmes.

The Swiss CRLS website (11) ( informs on the purpose and scope of incident reporting and learning. As with the UK CPiRLS, only chiropractors can submit and read reports on the password-protected website. Reports and discussions are kept totally anonymous. The password-secured forum is user-friendly and the reporting procedure is clear. Different to the UK CPiRLS the Swiss chiropractor describes the incident with a first reflection without categorisation. That means the user simply analyses what went wrong and what first action has to be taken. Regular, timely and effective feedback by experts regarding proposed action is essential.

A new supporting team was created in 2009 and a workshop --dealing with structured and systematic analysis of real-life adverse events in chiropractic care--was offered to a few chiropractors (12) in order to promote a climate of openness, to move away from finger pointing and routine assignation of blame, and to facilitate the production of formal reports. The London Protocol (13) was the chosen analysis method. Several follow-up workshops have been held since.


In order to facilitate our patients' care with a maximum chance of benefit and a minimum risk of harm, continuing professional development following under-graduate education must relate to self-directed, life-long learning by reflection and evidence to provide effective care as knowledge and practice evolve. (14) The essence of reflection is a deliberate process used to develop an understanding, or making sense, of a situation so that future actions can be informed. Critical incident reporting, and learning from it, is an excellent platform for practising reflection in order to learn, improve therapeutic relationships and develop professional practice. However, ethical considerations about confidentiality include who will have access to the reflection and for what purpose. Therefore incident reporting is best performed in a safe environment, anonymously, secure and supported by patient safety experts.


(1) Court D. Quest for patient safety in a challenging environment. Aust N Z J Obstet Gynaecol. 2003; 43: 97-100.

(2) Thiel HW, Bolton JE. The reporting of patient safety incidents--first experiences with the Chiropractic Reporting and Learning System (CRLS): a pilot study. Clinical Chiropractic. 2006; 9:139-149.

(3) Gunn SJ, Thiel HW, Bolton JE. British Chiropractic Association members' attitudes towards the Chiropractic Reporting and Learning System: a qualitative study. Clinical Chiropractic. 2008; 63-69.

(4) Cunliffe C, Johnson IJ, Selby J. Safety incidents, treatment complications and reactions recorded in a student teaching clinic: a retrospective analysis. Proceedings of the Association of Chiropractic Colleges Research Agenda Conference (ACC-RAC), Las Vegas, 2009.

(5) Finch RP, Bolton J, Cunliffe C, Jay TC, Thiel HW, Webster M, Connor C. Development of CPiRLS: The future of patient safety incident reporting and learning in the UK (abstract). In: Proceedings of the World Federation of Chiropractic Congress, Montreal, 2009.

(6) Wangler M, Zaugg B. Promotion of Patient Safety Competence among Licensed Chiropractors: Four Instructional Approaches. Thesis (MME) University of Berne, Switzerland, 2008 [cited 2011 January 27] Available from: masterthesen/thesen_anzeige.php?ID=70&sprache=de.

(7) Zaugg B, Wangler M. A model framework for patient safety training in chiropractic: a literature synthesis. J Manipulative Physiol Ther. 2009 Jul-Aug; 32(6):493-99.

(8) Bland CJ, Starnaman S, Wersal L, Moorehead-Rosenberg L, Zonia S, Henry R. Curricular change in medical schools: how to succeed. Acad Med. 2000; 75:575-594.

(9) Modak I, Sexton JB, Lux TR, Helmreich RL, Thomas EJ. Measuring safety culture in the ambulatory setting: the safety attitudes questionnaire--ambulatory version. J Gen Intern Med. 2007; 22:1-5.

(10) Sexton JB, Helmreich RL, Neilands TB, Rowan K, Vella K, Boyden J, et al. The Safety Attitudes Questionnaire: psychometric properties, benchmarking data, and emerging research. BMC Health Serv Res. 2006; 6:44.

(11) ChiroSuisse. Swiss Chiropractic Incident Reporting and Learning System CIRLS.

(12) Wangler M. Lernen aus Behandlungsfehlern Analyse gemass Methode ERA (London Protocol). Workshop Stiftung fur Patientensicherheit, 2009 [cited 2011 January 27] Available from: safety

(13) Taylor-Adams S; Vincent CA. Systems Analysis of Clinical Incidents: The London Protocol. Available from:

(14) WFME Office Copenhagen Denmark. Postgraduate Medical Education. WFME Global Standards for Quality Improvement. 2003 [cited 2008 March 30] Available from: WFME%20Postgraduate.pdf

Haymo Thiel, DC, MSc (Orth), FCCS(C), Dip Med Ed, PhD *

* Associate Professor and Vice-Principal, Anglo-European College of Chiropractic, 13-15 Parkwood Road, Bournemouth, UK, BH5 2DF.

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Title Annotation:Commentary
Author:Thiel, Haymo
Publication:Journal of the Canadian Chiropractic Association
Date:Jul 1, 2011
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