Event reporting systems: MERS-TM, surveillance--seeing and using the data below the waterline

Area of Science:

• Healthcare safety
• Risk management
• Patient safety

Background:

• Event reporting systems often exhibit significant variability, particularly in near-miss reporting, undermining quantitative reliability.
• Many organizations neglect near-miss events, classifying them as inconsequential if they fall outside established schemes.
• High reliability organizations recognize near misses as critical data for understanding system vulnerabilities.

Purpose of the Study:

• To highlight the value of near-miss reporting in identifying system weaknesses.
• To emphasize the role of near misses in studying recovery factors and promoting resilience.
• To advocate for near-miss reporting to maintain alertness in routine, automated tasks.

Main Methods:

• Analysis of reporting practices and organizational attitudes towards near-miss events.
• Examination of the utility of near-miss data for system improvement.
• Case study context: transfusion procedures as a high-risk, routine task.

Main Results:

• Variability in reporting rates, especially for near misses, compromises the reliability of event reporting systems.
• Near misses are often disregarded by organizations unless they are explicitly included in classification schemes.
• High reliability organizations utilize near misses to gain insights into system weaknesses and recovery factors.

Conclusions:

• Near-miss reporting is essential for uncovering latent system failures and enhancing safety protocols.
• Studying near misses provides opportunities to develop and promote recovery strategies.
• In routine procedures like blood transfusions, near-miss reporting fosters a crucial attitude of vigilance, countering the risks of automated behavior.