Casting a Wider Safety Net: The Promise of Electronic Safety Event Detection Systems

摘要

Accurate detection and reporting of adverse events is the cornerstone of understanding the epidemiology of safety issues occurring in health care systems. We must first understand the frequency, nature, and severity of the harm that results from the care we provide to be able to prevent and mitigate it. This activity is deceptively difficult and, as such, many different approaches have been documented in the literature. Each system, finding differing types of adverse events, brings with it advantages and limitations that are often complementary to each other, with very little overlap across methods.~(1-4) Better detection and reporting systems may assist with determining more accurate estimates of iatrogenic harm, the subject of much debate even 17 years after the seminal Institute of Medicine report, To Err Is Human,~(5-9) The current gold standard is incident reporting, which is usually voluntary, passive, subject to selection bias, and notoriously incomplete. It is estimated that the harm found via incident reporting systems vastly underestimates the true level of harm that occurs.10