Reporting, learning and the culture of safety.

Abstract

Systems that provide healthcare workers with the opportunity ot report hazards, hazardous situations errors, close calls and adverse events make it possible for an organization that receives such reports tu use these opportunities to learn and /or hold people accountable for their actions. When organizational learning is the primary goal, reporting should be confidential, voluntary and easy to perform and should lead to risk mitigation strategies following appropriate analysis; conversely, when the goal is accountability, reporting is more likely to be made mandatory. reporting systems do not necessarily equate to safer patient care and have been criticized for capturing too many mundane events but only a small minority of important events. reporting has been inappropriately equated with patients safety activity and mistakenly used for "measuring" system safety. However, if properly designed and supported, a reporting system can be an important component of an organizational strategy ot foster a safety culture.