In Situ Team-Based Simulation Training to Close the Loop on Event Reporting

Abstract

Reporting adverse events is often stigmatized in medicine. Adverse events are underreported. Underreporting has been linked to fear, the time required to complete a report, and a belief that reporting may not result in improvement.1 The reluctance to report is multidimensional and may relate to guilt, fear of punishment of self or others, fear of embarrassment, fear of litigation, and lack of confidence to effect change. Central to this fear is the widely held belief that errors and adverse events are due to carelessness and that blame must be assigned—often to the provider “at fault” or at the sharp end of the process. However, reporting of events offers an invaluable opportunity to identify latent systems issues and review and redesign error-trapping procedures and workflows. Without measurement, it is challenging to leverage adverse events as catalysts for targeted process improvement. Mandated reporting at the state and national levels is an influential catalyst to enhance data collection of adverse events. Aggregated data across varied practice settings are powerful. Mandated reporting alleviates some of the fear associated with reporting and increases reporting volume and relevance.