Implementing Change in Pediatric Care Practices Based on a Safety Event Reporting System

The Safety Event Reporting System (SERS) is an online reporting system for incident reporting. The neonatal intensive care unit at Children's Hospital Boston uses the reports from these events, along with staff input, to identify opportunities to change and improve clinical practice. Using these events as a chance to improve patient care and outcomes, instead of responding through punitive action, allows staff to feel comfortable reporting actual events and near misses. As a result, our unit has a high reporting rate for near misses, whereas there has been a decrease in serious, preventable events. This culture of inquiry and the nonpunitive system for reporting untoward events has led to quantifiable improvements in patient safety. In this paper, we describe SERS, discuss how we facilitate change through nonpunitive measures, and present measures we have used to improve patient safety in our unit in response to the SERS reports.