摘要：Background: Healthcare settings require a system that detects errors and near misses and learns from them to prevent their reoccurrence. Development of such a system requires engagement of all stakeholders. Retrospective reporting, analyzing and preventing future errors is currently the most prevalent approach to reducing harm to patients. It is important to point out that a recent report regarding reporting by the US Department of Health and Human Services Office of the Inspector General to Congress suggests that “current methods of detection of adverse events are far from adequate and risk misdirection of present efforts to improve safety based quality”. Recommended Approach: In an approach to overcome numerous limitations of current reporting methods, the authors propose a web-based user-friendly method that helps engagement of all stakeholders. Whilst invoking “improvement science” with “design science” it applies safety principles. It enables meaningful reporting that applies concepts from organizational models of accidents (based on Reason’s Trajectory). The design and use features are described in detail. Conclusion: Pilot tests with this reporting tool have been very encouraging. This trajectory model appears to help reporters to detect and understand that most accidents can be attributed to one or more of three weaknesses: situational, latent, and active.
关键词：Barriers to ReportingReliabilitySafetySystemTrajectory
