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Mandating error/near miss reporting only goes so far. It does nothing to incent providers to report potentially hazardous situations or other opportunities for improvement. Anyone that takes time to voluntarily report an error, near miss, or opportunity for improvement typically wants to see their feedback followed up on. Often there's a perception from providers that event/incident reports go in to an administrative "black hole" where action is seemingly never taken. Our event reporting system allows follow-up action such as RCA, action items, establishment of accountability (not blame), learning events, policy changes, and other corrective actions to be accessed directly from the original event report record, allowing all staff members with appropriate system rights to follow the outcome of their feedback through the entire improvement process.
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