Development and Implementation of the University of Texas Close Call Reporting System

Abstract

This report describes the development and implementation of The University of Texas Close Call Reporting System, an anonymous tool used to collect information about potential errors that do not reach the patient. The system was originally developed through experimentation, using a fund of knowledge collected in the aviation industry. A multidisciplinary health care team adapted this approach to develop a close call categorization scheme based on human-factor principles. This system, which is available in Web-based and paper formats, allows reporters to submit close calls in a risk-free manner and to enable the collection of rich information about the etiology of close calls. This information is used to identify areas of vulnerability and to develop interventions that can prevent problems from recurring. The development and implementation processes presented provide a comprehensive framework that can be used for future deployments of similar patient safety systems.