[MUSIC] In this video, we'll talk about how we can use event reports to improve safety and culture. Unfortunately, a current reality of healthcare is that events are happening frequently. Only a subset of events are actually reported into an organizations' patient safety database. This is what gives an organization data. The data that is reported can than be analyzed and used to provide information. That information can then be used to create organizational learning, identifying system defects that can be fixed in order to improve patient safety. This is what ultimately reduces harm. This learning process though is not stagnant, rather it's cyclical, and it's constantly a process of learning, unlearning and relearning. In addition, we know that it's important to get feedback back to frontline reporters in order to improve patient safety culture. Historically, our event reporting systems have focused on the first third of this, around data capture, and there's been less attention on the analysis and learning necessary to drive safety improvements. When we take a step back, we recognize that two-thirds of this diagram is really around analysis and learning, and that a preoccupation with failure is really a preoccupation with learning. Events are not submitted proportionally as severe harm, low harm and near miss events, as diagrammed in the first slide. Rather, the triangle on the left shows a situation in which many near misses are reported and only a few severe harm events. This is consistent with Heinrich's Triangle, where his study of workplace injuries found that for every major injury, there are 29 minor injuries and 300 non-injury accidents occurring. The diagram on the right shows an example in which an organization reports many severe harm events and only a few low harm and nearness events. When we think about the harm score there's all sorts of limitations. The harm score is one person's perspective of the event. It only captures a snapshot in time, and often the long-term impact to the patient may not be known. It does not account for the potential harm to other patients, and harm is often a matter of chance. Whether that event was in a near miss, or an event that involved severe harm, it could simply be a matter of chance. Lastly, there may be incentives to elevate or lower a harm score. For example, a frontline reporter who wants an event to fly under the radar, if it was a serious event, may downgrade the harm score. Or if it's an event that a frontline reporter would like to get a lot of attention on they may be inclined to elevate the harm score. So that more staff will see it, since often email notifications are linked to more severe harm events.