**5. The importance of anonymous event reporting in maintaining patient safety**

placing it above clinical productivity [45]. Institutional leaders are instrumental in creating a culture of honest disclosure, support, and constructive feedback. When errors occur, root cause analysis ensues to understand which specific systemic factors may have been contributory. The natural inclination to point fingers and blame a specific person or persons for making a mistake is discouraged. Adjustments to the system are then implemented to prevent the reoccurrence of the specific error in question. This includes sitting down with the individuals involved and addressing what went wrong and what needs to be done to prevent similar errors in the future. An action plan may include instituting failsafe mechanisms within the system to prevent performance of certain harmful actions. Development of a patient safety culture depends heavily on organizational structure and priorities, transformational leadership that can trickle down to other stakeholders as well as effective communication amongst all parties involved. Taken collectively, all of the above interventions act synergistically to

**Figure 1.** The relationship between institutional culture of safety and improved patient outcomes involves the presence of key foundational factors coupled with effective adoption of patient safety initiatives and the fostering of constructive

Once safe systems are in place, their preservation becomes critical. In addition, the long-term goal then transitions into permanent culture change that hopefully becomes a source of pride for both employees and the organization [7, 28]. Once a culture of safety is achieved, other aspects of institutional change can occur, including alignment of goals, especially between clinicians and administration. By association, one can also expect improved employee morale, enhanced quality of care, and other positive manifestations of a well-functioning organization. As a word of caution, the same can also occur "in reverse," where negative influences can insidiously and gradually erode various positive elements and influences within the insti-

help create and reinforce a culture of patient safety.

tutional culture [7, 47–50].

feedback.

4 Vignettes in Patient Safety - Volume 4

In many countries, incident reporting in health-care has become a well-accepted method of improving overall patient safety [56]. Strategic collection of adverse events and "near misses" from across our care delivery platforms allows safety specialists to efficiently analyze each event, identify potential underlying factors, and implement action plans based on this knowledge to help reduce systemic risk levels in the future [5, 7]. However, in the United States, medical errors continue to be significantly underreported, as exemplified in a study of over 1600 hospitals which concluded that substantial proportion of facilities lacked adequate event reporting systems [57].

The overarching question then becomes, which components comprise a thorough, accurate, and effective reporting system design within health-care? Specifically, published studies identify several factors that are essential to constructive "incident reporting". These factors include: staff willingness to report incidents, removal of barriers to incident reporting, the overall culture surrounding reporting, classifying and monitoring the number of incidents reported, taxonomies for various types of patient safety events, and the constitution of incident reporting systems [58–60]. Moreover, one of the greatest challenges that exist with regards to the incident reporting process is determining a way to create a "no blame" culture and balancing team accountability versus individual responsibility [58–60].

Presently, reporting systems within health-care tend to place greater emphasis on collecting reports than on conducting advanced analyses and identifying learning opportunities that can be gleaned from the available wealth of information [61–63]. One study suggests that systems should focus on providing health-care professionals with feedback pertaining to incidents that occurred, including any action(s) taken, to then serve as an integral part of the cycle of continuous improvement and the creation of a culture of safety [64]. Health-care workers who feel protected by employers after disclosing an incident, primarily through anonymity, generally are more likely to report the event through established mechanisms, and the reported event can then be utilized as a constructive example for all staff in regards to reducing risks and embracing PS measures. In summary, appropriately structured, anonymous event reporting programs have contributed to significant changes in practices, including new care processes, constructive behavioral changes, as well as more realistic risk perception and awareness of the importance of a culture of safety.

**Author details**

USA

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Stanislaw P. Stawicki1

and Michael S. Firstenberg4

Bethlehem, Pennsylvania, USA

\*, Alyssa M. Green1

\*Address all correspondence to: stawicki.ace@gmail.com

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1 Department of Research and Innovation, St. Luke's University Health Network,

2 Department of Medicine, Section of Hematology and Oncology, St. Luke's University

3 Department of Surgery, Division of Vascular Surgery, St. Luke's University Health

4 Department of Surgery (Cardiothoracic), The Medical Center of Aurora, Aurora, Colorado,

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