The ECRI and ISMP Patient Safety Organization has reached a milestone: more than 5 million events reported since its inception. However, two thirds of the reports were about actual events that reached the patient. Only 15% were labeled as “near miss” events, incidences that were "close calls." This is despite the well-known fact that near miss events are 10 to 100 times more common than actual events. Why is that?
Patient safety experts have long emphasized the necessity of creating a culture in which healthcare providers can freely report errors or other potentially avoidable events. This information can be protected by submitting the report, and all the investigations associated with it, to a patient safety organization (PSO). An exception exists only for events that must be reported to the state or an accreditation agency, but even there, any investigations and deliberations are protected when reported to a PSO under the Patient Safety and Quality Improvement Act of 2005.