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Error Reporting and Disclosure.


In: Hughes RG, editor.


Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr. Chapter 35.
Advances in Patient Safety.


Sustained and collaborative efforts to reduce the occurrence and severity of health care errors are required so that safer, higher quality care results. To improve safety, error-reporting strategies should include identifying errors, admitting mistakes, correcting unsafe conditions, and reporting systems improvements to stakeholders. The greater the number of actual errors and near misses reported, the more reliable a health care organization or system could be, from a safety viewpoint, when systems improvements are consistent with error patterns. Clinicians appreciate seeing the results of the reports they submitted transformed into systems improvements. Understanding and communicating the root causes of errors and near misses can decrease the risk of future errors, and support the concept that health care errors are often systemic and multifactorial. Reporting errors and near misses may increase through voluntary reporting systems, because voluntary systems provide additional evidence that the blame/shame patterns are being eliminated in health care organizations and systems. Electronic error-reporting systems can possibly make the time required to report shorter, shorten the time for correcting unsafe conditions, and alert providers to emerging unsafe patterns. Some systems can also facilitate quality improvement initiatives through enhanced error-reporting systems. The benefits of Web-based health care reporting systems that clinicians find easy to use and see the effects of their reporting in changes to systems might ultimately reduce the incidence of serious errors, and significantly improve the safety and quality of health care afforded patients.

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