First few Article Sentences
In complex healthcare systems, a majority of adverse events-unintended patient harm resulting from medical care-are caused by breakdowns in systems and processes, not by poor practices or incompetent practitioners. Most adverse events are not random; they often occur because of weak systems and common root causes. Although each event is unique, the risks from one event to another are often similar and may go unnoticed if events are not reported and analyzed.
Oregon's confidential and voluntary Patient Safety Reporting Program (PSRP) has been working since 2006 to gather information on adverse events that occur in Oregon healthcare facilities. The goal of the reporting program is to understand why and how adverse events occur and share aggregate information statewide to improve healthcare in Oregon.