Blameless reporting systems

A key to the success of WalkRounds is that staff members feel safe sharing information. At BWH, discussion and analysis from WalkRounds are tied in with the hospital s peer review committee and therefore protected by the state s peer review statutes. A blameless reporting system also helps staff members feel safe discussing their experiences. 

The implementation of a voluntary blameless reporting system is a deep cultural intervention in an organization that legitimizes transparency of system vulnerability, nurtures an alert field, and empowers front-line providers to expose risks. In turn, the front line learns to expect responses from managers at the blunt end to support the work of improvement. The few organizations in health care that have developed reporting systems believe that the effort is 75 percent social and only 25 percent technical (personal communication from Anne-Claire France, former director of the Center for Healthcare Improvement, Memorial Hermann Healthcare... 

Critical Principles for Success in a Blameless Reporting System... 

Aeronautics and Space Administration (NASA) for the aviation industry. NASA, external to the industry, accepts confldential narratives about near misses and accidents up to the point of a crash (Reynard, Billings, Cheaney, and Hardy, 1986). The system is voluntary, confidential, and nonpunitive, and its purpose is to collect and use incident data to improve the national aviation system. The ASRS supports aviation system policy, planning, and improvement and strengthens the foundation of human factors research in aviation by identifying deficiencies for correction by appropriate authorities. The Veterans Administration is the only health care entity to contract with NASA for a blameless reporting system at this time. 

Patient Safety Reporting System (PSRS) (6) A prototype blameless reporting system established in 2000 by NASA and the Veterans Administration. The PSRS emphasizes the reporting of near misses (see definition above). 

B2. Install Blameless Reporting System to Support Safety. 

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