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Confidential Reporting Systems
Introduction |
PSIS |
Systems Approach |
PSRS
NCPS offers caregivers two systems that can be used to report adverse events and close calls.
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NCPS has developed an internal, confidential, non-punitive system— the Patient Safety Information System (nicknamed “SPOT”). This reporting and analysis system allows users to electronically document patient safety information from across the VA so that “lessons learned” can benefit the entire system.
More than 14,700 root cause analysis (RCA) reports and 427,900 safety reports have been recorded in SPOT since NCPS was established.
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The systems approach to problem solving requires a willingness to report problems or potential problems so that solutions can be developed and implemented.
Willingness and an avenue to report problems and potential problems is essential to safe care because you can’t fix what you don’t know about.
In particular, reporting close calls is important. They provide an exceptional opportunity for learning and afford the chance to develop preventive strategies and actions before a patient is harmed. That’s because close calls have been shown to be anywhere from 3-to-300 times more common than actual adverse events.
Because of their importance, close calls are given the same level of scrutiny as adverse events that result in actual harm.
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NCPS also contracts with NASA to manage an additional external reporting system, the voluntary Patient Safety Reporting System (PSRS).
PSRS can be used to report adverse events and close calls in VA facilities. This external, non-punitive “learning program” provides VA employees a “safety valve” to confidentially report adverse events or close calls that, for whatever reason, wouldn’t be reported elsewhere.
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Patient Safety Reporting System
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National Center for Patient Safety