title: Event reporting systems: MERS-TM, surveillance--seeing and using the data below the waterline.
abstract: A significant variability in reporting rates, particularly of near-miss events, limits the quantitative reliability of event reporting. Organizations tend to disregard events such as near misses if they are "below the waterline", and outside their classification schemes. High reliability organizations, on the other hand, see near misses as valuable information regarding a system's weaknesses. Another value of near-miss reporting is the opportunity to study recovery factors in order to promote recovery once failure occurs. Since transfusion procedures are well-practised routines, they are often performed as automatic behaviours, vulnerable to interruption and unanticipated occurrences. Data fed back from near-miss events are a useful means of countering this, by maintaining an attitude of alertness in task performance.
authors.affiliation: Department of Pathology, Columbia University, New York, NY 10032, USA. hsk18@columbia.edu
authors.forename: H S
authors.initials: HS
authors.lastname: Kaplan
mesh_terms: D001803:Blood Transfusion / Q000592:standards*; D006801:Humans; D017751:Safety Management / Q000458:organization & administration; D018571:Sentinel Surveillance; D065227:Transfusion Reaction