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Qual Saf Health Care 12:ii68-ii72 doi:10.1136/qhc.12.suppl_2.ii68
  • Original Article

Organization of event reporting data for sense making and system improvement

  1. H S Kaplan,
  2. B Rabin Fastman
  1. College of Physicians and Surgeons, Columbia University, 622 West 168th Street, New York, NY, USA
  1. Correspondence to:
 H S Kaplan MD
 College of Physicians and Surgeons, Columbia University, Harkness Pavilion HP417, 622 West 168th Street, New York, NY, USA; hsk18{at}columbia.edu

    Abstract

    Feedback and demonstrable local usefulness are critical determinants for adopting event reporting by an organization. The classification schemes used by an organization determine whether an event is recognized or ignored. Near miss events, by their frequency and information content concerning recovery, merit recognition. “Just” cultures are learning cultures that provide a safe haven in which errors may be reported without the fear of disciplinary action in events without reckless behavior. As event report databases grow, selection and prioritization for in depth investigation become critical issues. Risk assessment tools and similarity matching approaches such as in case based reasoning are useful in this regard. Root cause analysis provides a framework for the collection, analysis, and trending of event data. The importance of both internal and external risk communication as valuable reporting system components may be overlooked.