Create a Reporting System

​In a culture of safety, staff members are aware of safety issues and are free to report conditions that could lead to near misses or actual adverse events. This open exchange of information requires the management to have a non-punitive response philosophy that rewards reporting of safety issues and events and does not punish staff members involved in errors or adverse events related to system failures.


  • Communicate the reporting policy to the staff during Patient Safety Leadership WalkRounds™.
  • Adopt a non-punitive reporting policy.
  • Reinforce the non-punitive management philosophy by asking staff members who have reported safety issues, near misses, or adverse events to share their story with others, including how the management supported them.
  • Consider staff members’ safety reports — and their involvement in other safety initiatives — favorably in their annual performance reviews.
  • Train managers to identify human factors and system failures in errors and adverse events.
  • Let reporters know something will be done with their report, that the system works. That way they feel that their report will be useful.


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