Capturing, Reporting, and Learning from Adverse Events



Research studies have validated an epidemic of grossly underreported, preventable injuries due to medical management. Recent policy aims have placed high priority on improving incident reporting as the first step in addressing patient injuries and have called for translation of lessons from other industries. Complex nonmedical industries have evolved incident reporting systems that focus on near misses, provide incentives for voluntary reporting, ensure confidentiality while bolstering accountability, and emphasize a systems approach to data collection, analysis, and improvement. Reporting of near misses over adverse events offers numerous benefits, greater frequency allowing quantitative analysis, fewer barriers to data collection, limited liability, and recovery patterns that can be captured, studied, and used for improvement. Education and engagement of all healthcare stakeholders, including patients and caregivers, and negotiation of their conflicting goals will be necessary to change the balance of barrier incentives in favor of implementing effective surgical reporting systems.


Reporting Adverse events Learning systems Patient safety Patient harm Sensemaking Near misses 


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Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Department of SurgeryAscension Saint Agnes Hospital, Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Clinical Professor, Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research ScholarChildren’s Hospital of Michigan, Wayne State University School of MedicineDetroitUSA

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