Reporting systems confidential

CHIRP (Confidential Human Factors Incident Reporting Programme) is a clear example of a successful voluntary near miss reporting system, run by the UK s RAF s Institute of Aviation Medicine. Each year about 200 pilots and air traffic controllers report to CHIRP, not anonymously but in complete confidence, about mistakes they have made in the air and why they believe they made them (Greene, 1990). 

The Medication Error Reporting Program (MERP) is a voluntary program administered by the U.S. Pharmacopeia (USP) in conjxmction with the ISMP. This confidential reporting system improves patient safety by alerting practitioners and the industry to potential or actual problems. Practitioners are asked to report errors and near misses to this program so that others learn from errors and prevent similar errors in the future. 

Part two of the plan calls for establishing an error-reporting system. The report suggests a two-prong approach in which a national program is first implemented at the state level to detect the most serious errors. Then, a voluntary, confidential system is established to encourage individuals to report near misses. Pharmacists can participate in both activities to provide their expertise and help create such systems in their institutions. 

The ability of the compliance officer to receive complaints from employees is vital to an effective compliance program. An effective reporting system alerts the corporate compliance committee to violations before the government discovers them or they become the subject of a qui tarn lawsuif. Any employee who recognizes fhe possible occurrence of fraud and abuse should have a means of reporting the violation without fear of repercussions. To facilitate this, written confidentiality and nonretaliation policies should be developed and distributed to all employees. To enable the... 

Patient confidentiality concerns may also limit the development of syndromic surveillance systems. Any automated reporting system will require confidentiality safeguards, such as the use of aggregated information (12). However, even with aggregated data, sorting by characteristics such as race, age, and zip code could still lead to identification of individuals. Therefore, surveillance systems will need standards restricting the display of aggregated data when numbers of events or population sizes are small (14). On the other hand, public health authorities may still need to be able to re-identify individuals to follow-up on cases (11). 

Given continued questions of timeliness, accuracy, confidentiality, and given the administrative hurdles facing development of complete, integrated syndromic surveillance systems, it is unlikely that automated syndromic surveillance systems will replace traditional clinician and laboratory initiated reporting systems within the next few years. Studies of the performance of syndromic surveillance systems are difficult due to the low frequency of large outbreaks of most diseases (11). Even if syndromic surveillance systems eventually demonstrate some utility, it is likely that they will complement, rather than replace, traditional clinician, and laboratory reporting. 

Many factors have been highlighted as supporting the development of an effective patient safety culture. Some of the important ones are management (i.e., management commitment, ability, leadership, coordination, and flexibility), immediate supervisors (i.e., open-door policy, participation, and support correct behavior), reporting system (i.e., reporting near-miss, no-blame culture, analysis of error, open-door policy, confidentiality, and feedback). 

Diagnose the error-inducing conditions by obtaining accirrate data on current practices (through confidential reporting systems, sirrveys of personnel, and... 

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. 

A. Develop confidential, anonymous, open structure accident (error) and failure reporting system that is user-friendly and exceeds current reporting rate. 

The organization offers all employees and medical staff a user-friendly, easily accessible, confidential, narrative reporting system for recognized risks, near misses, and adverse events. 

In the U.S. aviation industry, the Aviation Safety Reporting System (ASRS) has been collecting confidential, voluntary reports of close calls (near miss incidents) from pilots, flight attendants, and air traffic controllers since 1976. The system was established after TWA Flight 514 crashed on approach to Dulles... 

The Patient Safety Reporting System (PSRS) is a program modeled on the Aviation Safety Reporting System and developed by the U.S. Department of Veterans Affairs (VA) and the National Aeronautics and Space Administration (NASA) to monitor patient safety through voluntary, confidential reports. 

CIRAS (Confidential Incident Reporting and Analysis System) is a confidential reporting system modeled on ASRS and originally developed by the University of Strathclyde for use in the Scottish rail industry. 

Procedures. Standardized error reporting system Competencies and Procedures. All members of staff given access to and training in incident reporting system Procedures. Incident reporting system should be confidential, anonymous, blame free, and non-punishable (where appropriate)... 

Collect data in a proactive but nonpunitive manner. Learn from errors to identify trends that may reveal problems with care. Two incentives for reporting include immunity and confidentiality. Effective reporting procedures help determine educational and training needs. Accurate reporting of errors can help identify policies needing revision. Reporting systems should collect information... 

O Leary, M. and Chappell, S. L. (1996). Confidential incident reporting systems create vital awareness of safety problems. International Civil Aviation Organization Journal, 51, 11-13. 

The critical incident technique was first described by Flanagan (1954) and was used during World War II to analyze "near-miss incidents." The war time studies of "pilot errors" by Fitts and Jones (1947) are the classic studies using this technique. The technique can be applied in different ways. The most common application is to ask individuals to describe situations involving errors made by themselves or their colleagues. Another, more systematic approach is to get them to fill in reports on critical incidents on a weekly basis. One recent development of the technique has been used in the aviation world, to solicit reports from aircraft crews in an anonjmrous or confidential way, on incidents in aircraft operations. Such data collection systems will be discussed more thoroughly in Chapter 6. 

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