My “aha moment” today was when Crystal mentioned that administration only knows about 4% of adverse events which occur because they are only being made aware of the events which are really catastrophic. However, if they had been made aware of every single adverse event, regardless of level of harm, there could have been strategies, plans, and policies put in place which may have prevented much of the 4% of catastrophic events.
This is a point that I intend to share with my team to encourage them to report patient safety events. I think many of my co-workers are only reporting the events which actually reach the patient, I am guilty of this myself. However I am realizing that it is of great importance to report the good catches so administration is aware of potential safety issues.