The Society of Hospital Medicine (SHM) is a medical society comprised of hospitalists that exists to promote exceptional care for hospitalized patients.
The commitment to reporting adverse events is essential for healthcare systems in order to prevent safety events. This commitment needs to occur from the top down and bottom up. However, because most reporting is done voluntarily by front-line nurses and providers, many events go unreported. Voluntary reporting is often underutilized, subject to selection bias, and may capture only a fraction of safety events (Shojania1). To create a successful adverse event reporting and management (AERM) plan, institutions must address these limitations to event reporting. These strategies may help: investing in an easy-to-use reporting system, establishing a blame-free, retaliation-free reporting culture, and building a multi-disciplinary team to manage safety events. This team should be engaged, data-driven, and able to interpret events and event patterns and develop event reduction plans, using a robust event management system like Root Causes Analysis and Actions (RCA2). And it must be empowered to make system changes based on its findings. Institutions should also consider involving patient/family members in event management to gain vital perspectives and repair relationships.
Find the IHI RCA2 source document here:
https://www.ihi.org/resources/tools/rca2-improving-root-cause-analyses-and-actions-prevent-harm
Similar information is available in the VA system guide to performing RCA2:
https://www.patientsafety.va.gov/docs/RCA_Guidebook_10212020.pdf
For a more detailed look at AERM systems and RCA2, review this Executive Summary.