Optimizing Event Reporting to Drive a Culture of Learning and Safety: A System-Based Approach to Mitigating Harm Through Near-Miss and No-Harm Reporting.

Abstract

Background: Patient safety event reporting systems are essential for identifying potential risks and improving patient outcomes. However, traditional systems frequently face issues of under-reporting, particularly concerning near-miss and no-harm events, thereby limiting opportunities for organizational learning and harm prevention. This initiative used quality improvement principles to design a new reporting system at our institution to enhance safety culture.

Methods: Following extensive stakeholder feedback and multidisciplinary collaboration, a new system was implemented on July 22, 2022. Key features included streamlined reporting, centralized data analysis, and enhanced transparency.

Results: Overall event reporting as well as proportional reporting of near-miss and no-harm events increased significantly from around 60% preimplementation to 80% after implementation. Staff engagement also improved, as shown by a steady rise in the number of unique event reporters and reviewers.

Conclusions: The new reporting system has improved reporting overall, with increases in near-miss and no-harm events, along with increased staff engagement with the reporting and review process. Our experience offers practical lessons for institutions seeking to strengthen the learning value of event reporting systems. The principles we identified with simplifying ease of use, integrating into the EHR, improving data transparency, and encouraging greater involvement with event review, along with clear oversight protocols, apply beyond our institution and are not limited to a specific PSRS product or system. These initial outcomes support a culture of safety and bolster organizational learning, with future study needed on long-term effects on patient safety outcomes, staff involvement, and increased trust.