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Qual Saf Health Care. Dec 2003; 12(Suppl 2): ii68–ii72.
PMCID: PMC1765770

Organization of event reporting data for sense making and system improvement

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.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Kaplan HS, Battles JB, Van der Schaaf TW, Shea CE, Mercer SQ. Identification and classification of the causes of events in transfusion medicine. Transfusion. 1998 Nov-Dec;38(11-12):1071–1081. [PubMed]
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