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What information should my staff include in reports of adverse events and near misses?


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Data are the objective information needed to demonstrate the need for certain actions to be taken in order for the desired change to take place. Data aggregation helps identify problems, offers consensus on best practices and evidence-based medicine, and affords the opportunity to share information with colleagues and peers. By using an automated or electronic reporting system, data collection, analysis, and reporting can be simplified. However, there does need to be a systematic approach to data collection, and data can be collected via a multitude of ways-through chart reviews, incident reports, lawsuit and claims reporting, financial and medical record coding, surveys, and many other data collection activities. The Institute of Medicine recommends that a combination of narrative and coded elements be collected when it comes to what information should be provided about near misses and adverse events and should, at a minimum, include the following:

  • The discovery-who and how the event was discovered
  • The event-type of near miss/event
  • Where, when, and who was involved
  • Severity and preventability of the event
  • Likelihood of recurrence
  • Ancillary information-patient and product information, as applicable1

 When staff members are assured that the data being reported will not be used punitively but to develop better practices of care, reporting will increase and staff members will begin to include more information than just those data elements listed above. Narrative data are just as important, (sometimes if not more so) as objective data because they can provide additional information pertinent to the circumstances surrounding the event (i.e., whether the event occurred at the change of a shift, whether there were a lot of visitors, or whether there were students present, etc.).

-Vivian B. Miller, BA, CPHQ, LHRM, CPHRM, FASHRM 

(May 2012)

1Solomon, Ronni, and Simons, Sherri, Data for Safety Actionable Knowledge Tack Force, Data for Safety: Turning Lessons Learned into Actionable Knowledge. American Society for Healthcare Risk Management of the American Hospital Association, 2008.