When an error occurs, what is the best practice for reporting and learning from the event?

• A. Ignore the error unless patient harm occurs.
• B. Document events, inform necessary parties, report per policy, participate in root cause analysis, implement changes, and monitor outcomes.
• C. Blame the individual responsible and minimize disclosure.
• D. Delay reporting until the patient is discharged.

Answer: (B)

When an error occurs, the best practice focuses on learning from the event by treating safety as a system issue rather than blaming a person. Start with documenting what happened in detail—what occurred, who was involved, when it happened, and the patient status. Then inform the necessary parties and report the event through the institution’s incident reporting process, following established policies. Next, participate in a root cause analysis to uncover underlying system factors that contributed to the error, using a structured approach rather than assigning blame. Develop and implement corrective actions to address those root causes, updating policies, workflows, checklists, or training as needed. Finally, monitor the outcomes to ensure the changes reduce recurrence and adjust as necessary.

This approach embodies a safety culture that prioritizes learning and prevention. Ignoring errors prevents improvement, blaming individuals undermines openness and reporting, and delaying reporting keeps patients at risk longer and stalls improvement efforts.