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Capturing, Reporting, and Learning from Adverse Events

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Surgical Patient Care

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Abstract

Research studies have validated an epidemic of grossly underreported, preventable injuries due to medical management. Recent policy aims have placed high priority on improving incident reporting as the first step in addressing patient injuries and have called for translation of lessons from other industries. Complex nonmedical industries have evolved incident reporting systems that focus on near misses, provide incentives for voluntary reporting, ensure confidentiality while bolstering accountability, and emphasize a systems approach to data collection, analysis, and improvement. Reporting of near misses over adverse events offers numerous benefits, greater frequency allowing quantitative analysis, fewer barriers to data collection, limited liability, and recovery patterns that can be captured, studied, and used for improvement. Education and engagement of all healthcare stakeholders, including patients and caregivers, and negotiation of their conflicting goals will be necessary to change the balance of barrier incentives in favor of implementing effective surgical reporting systems.

“… The value of history lies in the fact that we learn by it from the mistakes of others, as opposed to learning from our own which is a slow process.”

—W. Stanley Sykes, 1894–1961

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Author information

Authors and Affiliations

  1. Department of Surgery, Ascension Saint Agnes Hospital, Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Juan A. Sanchez MD, MPA

  2. Clinical Professor, Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, 5057 Woodward Avenue, Suite 13001, Detroit, MI, 48202, USA

    Paul Barach BSc, MD, MPH

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  1. Juan A. Sanchez MD, MPA
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  2. Paul Barach BSc, MD, MPH
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Corresponding author

Correspondence to Juan A. Sanchez MD, MPA .

Editor information

Editors and Affiliations

  1. Department of Surgery Ascension Saint Agnes Hospital Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Juan A. Sanchez

  2. Children’s Cardiomyopathy Foundation and Kyle John Rymiszewski Research Scholar, Children’s Hospital of Michigan, Wayne State University School of Medicine, Detroit, MI, USA

    Paul Barach

  3. Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    Julie K. Johnson

  4. Division of Cardiovascular Surgery Johns Hopkins All Children’s Heart Institute Johns Hopkins All Children’s Hospital, Johns Hopkins University, Saint Petersburg, FL, USA

    Jeffrey P. Jacobs

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Sanchez, J.A., Barach, P. (2017). Capturing, Reporting, and Learning from Adverse Events. In: Sanchez, J., Barach, P., Johnson, J., Jacobs, J. (eds) Surgical Patient Care. Springer, Cham. https://doi.org/10.1007/978-3-319-44010-1_40

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  • DOI: https://doi.org/10.1007/978-3-319-44010-1_40

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