The need to improve reporting and analysis of non-routine events, near misses and preventable failures in the care of patients has emerged as one of the most important and challenging opportunities in the growing international movement to advance patient safety. Ideally, event reporting serves many functions in complex socio-technical systems, among them an indispensable contribution to organizational learning, continuous systems improvement, and steady reinforcement of the safety culture.
     The Institute of Medicine has recommended establishing strong mandatory and voluntary medical reporting efforts. Mandatory reporting systems ideally concentrate on serious events in which death or harm to a patient occurred, and serve to improve public accountability as well as sharing important lessons. Voluntary reporting systems may focus on events which result in no harm despite hazards and the potential for injury, and have a larger emphasis on learning than accountability.
    Literature and experience show that the causes underlying near-miss events are similar to those associated with harm, and often offer rich and complex insights into systems operations. The study of near misses also enables the study of patterns of recovery, i.e. possible reasons why the trajectory of the event was diverted or interrupted by skill, system design or chance. In the absence of the specter of liability and blame, clinicians and others are also more likely to participate in nuanced, in-depth analysis of what happened and provide human factors and team information not available in any other venue (charts, monitor print outs, etc). Near misses are much more numerous than serious harm events, and lend themselves to trending and pattern analysis.
    The UC Simulation Center was created with funding from the U.S. Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation, and the Advanced Biomedical Tele-Collaboration Testbed, along with support from the University of Chicago Hospitals, the Biological Sciences Division, and the Department of Anesthesia and Critical Care. The center currently utilizes advanced high-fidelity Human Patient Simulators and the Access Grid tele-collaboration technology to study simulated medical events and scenarios in an immersive environment. The facility design supports interdisciplinary, multi-patient clinical venues to enable investigation and training for systems-level issues.

MERS-TM & MERS-TH
Through the support of the National Heart, Lung, and Blood Institute, Columbia University’s Dr. Harold Kaplan and colleagues at the University of Texas developed the Medical Event Reporting System – Transfusion Medicine (MERS-TM) to track events involving administration of blood products. An expanded version under development, MERS – TH (Total Hospital), supports capture and analysis of untoward events in all areas of hospital operations.

Some innovative features of MERS include:
• A dual coding system, utilizing both clinical and causal codes. The causal codes are generalizable to all safety critical industries, and are based on the Eindhoven system.

• An advanced search function enabling sophisticated event matching and pattern analysis of both user’s individual datasets and benchmarking with aggregated MERS data

• The ability to electronically represent and aggregate
 condensed, coded root cause analysis flow diagrams

• The ability to use a Risk Assessment index to assign a risk number to each event and create trendable, organizational memory for the frequency and severity of hazards

• Audit trail for event processing, simultaneous multi-user functions, and tiered password protected data accessibility