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PSNet: Patient Safety Network
Journal Article

Development and preliminary testing of the Coordination Process Error Reporting Tool (CPERT), a prospective clinical surveillance mechanism for teamwork errors in the pediatric cardiac ICU.

Bates KE, Shea JA, Bird GL, et al. Joint Commission journal on quality and patient safety. 2016;42:562-AP4.

Hospitals rely on incident reporting systems to detect safety issues, but these systems are voluntary and do not capture all adverse events or near misses. Researchers developed and tested a prospective surveillance tool to identify teamwork errors in the pediatric intensive care unit. They found that this tool helped uncover safety issues not captured by the hospital's patient safety reporting system.