NCPS has developed an internal, confidential, non-punitive system— the Patient Safety Information System (nicknamed “SPOT”). This reporting and analysis system allows users to electronically document patient safety information from across the VA so that “lessons learned” can benefit the entire system.
More than 16,500 root cause analysis (RCA) reports and nearly 700,000 safety reports have been recorded in SPOT since NCPS was established.
The systems approach to problem solving requires a willingness to report problems or potential problems so that solutions can be developed and implemented.
Willingness and an avenue to report problems and potential problems is essential to safe care because you can’t fix what you don’t know about.
In particular, reporting close calls is important. They provide an exceptional opportunity for learning and afford the chance to develop preventive strategies and actions before a patient is harmed. That’s because close calls have been shown to be anywhere from 3-to-300 times more common than actual adverse events.
Because of their importance, close calls are given the same level of scrutiny as adverse events that result in actual harm.