Mandatory Error Reporting
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Medication Error Reporting Procedure
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navigation, searchHERE Article Information Category: Human Behaviour Content source: SKYbrary Content control: SKYbrary Contents 1 Description 2 Mandatory and Voluntary Occurrence Reporting 3 Error Reporting Barriers 4 Related Articles 5 Further Reading Description Human error has been identified http://www.skybrary.aero/index.php/Error_Reporting as a dominant risk factor in aviation operations. The errors trapped within daily operations https://psnet.ahrq.gov/perspectives/perspective/43/advancing-patient-safety-through-state-reporting-systems are unlikely to be detected in the absence of effective error reporting. Error reporting is fundamental to the broad goal of error reduction. At the organisational level, error reporting will only become an accepted and encouraged activity if aviation personnel feel safe in doing so. The following list depicts some good industry practices. It identifies common error reporting error reporting principles that can help to ensure that errors do not go unreported: Error reports should be used to find the root causes of the errors, not to establish blame or liability. Personnel involved in reporting should be given feedback of the results of the error analysis. The use of a non-punitive approach to reporting is recommended to encourage personnel to report errors. The mechanism for reporting errors should error reporting system be made straightforward and easily accessible at all organizational levels. The electronic or hard copy reporting forms should be made unambiguous and easy to use. Mandatory and Voluntary Occurrence Reporting Voluntary error reporting facilitates the collection of information on actual or potential safety deficiencies thus contributing to the identification and implementation of safety improvement measures. It is a proactive process and should include related arrangements for collecting information about safety concerns, issues and hazards which otherwise will not be revealed by a mandatory reporting system. The principles of the successful voluntary reporting systems are described in detail in the dedicated article Voluntary Occurrence Reporting Mandatory reporting systems imply that the individual at fault must report the error. However, analysis of serious errors almost always reveals multiple system failures and often the involvement of many individuals. The requirements for mandatory reporting is discussed in detail in the dedicated SKYbrary article Mandatory Occurrence Reporting Error Reporting Barriers Barriers to reporting must be addressed before a reporting system can have a substantial impact on operational safety. The barriers to error reporting fall primarily into the following categories: Fear of individual punishment or organisational repercussion; Belief that the operational error can be used as a measure of the individual's competence. Generally, the vo
Me Forgot Password? Login or Sign up for a Free Account My Topics of Interest My CME My Profile Sign Out Home Topics Issues WebM&M Cases Perspectives Primers Submit Case CME / CEU Training Catalog Info Glossary About PSNet Help & FAQ Contact PSNet Email Updates Editorial Team Technical Expert/Advisory Panel Terms & Conditions / Copyright PSNet Privacy Policy External Link Disclaimer Perspectives on Safety Published June 2007 Advancing Patient Safety Through State Reporting Systems by Jill Rosenthal, MPH Topics Resource Type Perspectives on Safety › Perspective Approach to Improving Safety Audit and Feedback Public Reporting Regulation Error Analysis Setting of Care Hospitals Target Audience Health Care Executives and Administrators Policy Makers Error Types Epidemiology of Errors and Adverse Events More Share Facebook Twitter Linkedin Email Print Perspective Seven years ago, the Institute of Medicine (IOM) called on states to create mandatory reporting systems as part of a strategy to identify and learn about medical errors and ultimately to improve patient safety.(1) Since then, many states have responded by creating or improving reporting systems to collect information about hospital-based adverse events. These systems can provide states with an opportunity to strengthen their facility oversight functions, safeguard the public, and partner with providers to improve health care quality. As of April 2007, more than half of states (27) had passed legislation or created regulations related to hospital reporting of adverse events (26 are mandatory systems, one is voluntary).(2) The goals of state reporting systems may be twofold. First, many of these requirements are intended to hold health care facilities accountable for weaknesses in their systems. Secondly, they may strive to improve patient safety through analysis and dissemination of best practices and lessons learned, which could prevent recurrences. In this article, I will review the evolution of state error reporting systems, current trends,