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VA National Center for Patient Safety

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Confidential Reporting System

Patient Safety Information SystemClinician working on a tablet stands next to a laptop computer in a hospital unit. 

NCPS has developed an internal, confidential, non-punitive system— the Patient Safety Information System. This reporting and analysis system allows users to electronically document patient safety information from across the VA so that “lessons learned” can benefit the entire system.

A combined total of more than 1,000,000 root cause analysis reports and safety reports have been entered into the reporting system since it was established.

Confidentially is a key reason for the system's success. Because the Patient Safety Information System is part of a medical quality assurance program, the information within it is protected from disclosure under 38 U.S.C. 5705.

Taking the Systems Approach

The systems approach to problem solving requires a willingness to report problems or potential problems so that solutions can be developed and implemented. Willingness and an avenue to report problems and potential problems is essential to safe care because you can’t fix what you don’t know about.

In particular, reporting close calls is important. They provide an exceptional opportunity for learning and afford the chance to develop preventive strategies and actions before a patient is harmed. That’s because close calls have been shown to be as much as 300 times more common than actual adverse events.

Because of their importance, close calls are given the same level of scrutiny as adverse events that result in actual harm.