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Reporting near misses: get "Mad"!

Staff Development Weekly: Insight on Evidence-Based Practice in Education, February 6, 2004

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Are you looking for innovative ways to encourage reporting of near misses, medical errors, or adverse events? Here's a tip from your colleagues at Centra Health, a regional health care system in Central Virginia. Staff members sought a method to enhance near missed events, so their Patient Safety Committee created a program called the "Make a difference" or "Mad" Pad as part of the system's ongoing patient safety and "blameless" culture initiatives. The Mad Pad began as a literal pad of paper three years ago and evolved into an electronic form after two years. The forms are submitted anonymously (as there is no mandatory log-in for most uses of their intranet) and there is a designated department to follow up with each report. The online forms are available for viewing by any staff member. The Mad Pad can also be submitted by paper and both versions have been well received by staff.

Be sure to include the following information if you'd like to test the Mad Pad at your facility:

1. Title
2. Category (i.e., dispensing; order entry; prescribing)
3. Brief Description of NEAR MISS being addressed (include possible causes or factors contributing to this error)
4. Suggestions for prevention

Editor's note: The above tip was printed with permission by Regina L. Phelps, RN, MN, Director, Education Services, Centra Health.

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