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PSNet: Patient Safety Network
Journal Article

Patient safety reporting systems: sustained quality improvement using a multidisciplinary team and "Good Catch" awards.

Herzer KR, Mirrer M, Xie Y, et al. The Joint Commission Journal on Quality and Patient Safety. 2016;38.

A major limitation of voluntary error reporting systems is that many hospitals do not reliably feed back the results of error investigations to the reporting providers and do not have formal mechanisms for translating reported errors into safety improvement efforts. This article describes a successful attempt to encourage voluntary error reporting by rewarding those who report errors, implementing a multidisciplinary team to review and address problems, and following up to ensure improvement efforts are sustained over time. The results provide a practical template for safety professionals to maximize the utility of voluntarily reported errors.