![]() Reports are usually submitted in confidence outside of the public arena and no penalties or fines are issued around a specific case. ![]() Reporting systems that focus on safety improvement are "voluntary reporting systems." The focus of voluntary systems is usually on errors that resulted in no harm (sometimes referred to as "near misses") or very minimal patient harm. While safety experts recognize thatĮrrors resulting in serious harm are the "tip of the iceberg," they represent the small subset of errors that signal major system breakdowns with grave consequences for patients. Third, they require all health care organizations to make some level of investment in patient safety, thus creating a more level playing field. Second, they provide an incentive to health care organizations to improve patient safety in order to avoid the potential penalties and public exposure. First, they provide the public with a minimum level of protection by assuring that the most serious errors are reported and investigated and appropriate follow-up action is taken. Most mandatory reporting systems are operated by state regulatory programs that have the authority to investigate specific cases and issue penalties or fines for wrong-doing. Reporting systems whose primary purpose is to hold providers accountable are "mandatory reporting systems." Reporting focuses on errors associated with serious injuries or death. Conceptually, these purposes are not incompatible, but in reality, they can prove difficult to satisfy simultaneously. They can hold providers accountable for performance or, alternatively, they can provide information that leads to improved safety. Reporting systems have the potential to serve two important functions. One way to learn from errors is to establish a reporting system. ![]() Although the previous chapter talked about creating and disseminating new knowledge to prevent errors from ever happening, this chapter looks at what happens after an error occurs and how to learn from errors and prevent their recurrence. ![]()
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