Developing a Prospective Incident-Reporting System for Clinical Perfusion Practice in the United States

For nearly 20 years, prominent perfusionists have called for a perfusion-centric prospective incident-reporting system to collect near-miss and patient harm incidents that occur during clinical practice in the United States. In this article, we describe the development of a widely available prospective incident-reporting system for use by perfusionists in the United States. The system was developed in three phases: literature review, system incorporation, and submission for listing as a Patient Safety Organization (PSO). It is anticipated that the knowledge gained from analysis of events contributed to this PSO-protected reporting system will lead to improvements in safety and quality of perfusion services, as well as expanding the understanding of best practices in training, equipment use, system design, and simulation scenarios.