When a “never event,” a catastrophic failure of care resulting in significant harm or death to a patient occurs, a hospital may focus on capturing and analyzing data on the event and classifying it. But how often does a hospital translate findings into actionable and measurable programs to improve safety?

When a critical incident occurs, the first step is to assess what happened, says Andy Weissberg, senior vice president at Quantros, a vendor of safety software supporting analytics, incident response and clinical quality reporting. Then, a hospital will conduct investigations and analyses then check off the appropriate compliance and peer review boxes on a form.

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