Patient Safety Primer: Voluntary Patient Safety Event Reporting (Incident Reporting)

This AHRQ primer provides background information on voluntary patient safety event reporting
(incident reporting), including key components of an effective event reporting system,
limitations of event reporting, and how event reports can be used to improve safety.

Multifaceted Program Increases Reporting of Potential Errors, Leads to Action Plans to Enhance Safety

This featured profile is available on the Agency for Healthcare Research and Quality’s Health
Care Innovations Exchange Web site. The University of Texas M.D. Anderson Cancer Center
implemented a multifaceted initiative, known as the Good Catch Program. The program was
designed to increase the reporting of potential errors related to medication, equipment, and
patient care. Key elements of the program include (1) a change in use of terminology from
negative to positive terms and phrases (e.g., from “close call” or “near miss” to “good catch”);
(2) friendly, team-based competition to promote reporting; (3) development of an end-of-shift
safety report; (4) executive leadership-sponsored rounds and incentives; and (5) a
multidisciplinary workgroup to promote reporting. The program increased the reporting of
potential errors dramatically, by 1,468 percent, in the 6-month pilot phase of the program and
spurred the development of action plans designed to address the common causes of potential


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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