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incident reporting, medical errors, safety culture, service quality



  1. Weingart, Saul N. MD, PhD
  2. Price, Jessica JD
  3. Duncombe, Deborah MHP
  4. Connor, Maureen MPH, RN
  5. Conley, Karen MS, RN
  6. Conlin, Genevieve J. MS, MBA, MEd, RN
  7. Sullivan, Amy M. EdD
  8. Powell, Mark MS
  9. Ponte, Patricia Reid DNSc, RN, FAAN, CNAA
  10. Bierer, Barbara E. MD


This article examines whether a patient safety "champion" on an ambulatory chemotherapy infusion unit can increase reporting of adverse events and close calls. Reporting rates increased substantially on both intervention and control units. It was accompanied by more reports of medical errors and conditions that worried staff and fewer reports of service quality incidents. The facilitated reporting method described here is a novel approach to incident reporting, complements the spontaneous reporting systems used in hospitals and some ambulatory care settings, and may help to build a safety culture. By identifying errors and worrisome conditions, it may help managers identify problems before they lead to harm.