Incident Reporting Systems

Culture of Safety

All hospitals affiliated with Emory University School of Medicine share a commitment to creating a safe environment for patient care.

Commitment to Just Culture Principles

All EUSOM affiliated teaching hospitals commit to Just Culture principles, as described in these obligations:

Obligations of individual workers, including physicians

  1. Use your best judgment in maintaining safety, including using safe practices and protocols you have been trained on
  2. Report near misses and other events as instructed

Obligations of your health care systems

  1. Create a safe environment for reporting
  2. Continually improve our ability to deliver safe care to patients
  3. Support workers in making safe choices through coaching
  4. Reserve discipline for instances of reckless behavior when a person knowingly AND unjustifiably chose an unsafe action

Disclosure of mistakes and adverse events

All EUSOM affiliated teaching hospitals and health professionals share an ethical commitment to be transparent with patients and families when things go wrong.  Trust between patients and the medical team may be strengthened or threatened in the process of disclosure.  Keep the following in mind:

  1. Notify your attending and resident right away
  2. Notify risk managers as soon as possible
  3. With the help of your team, start communication with patients or families soon. You don’t have to have all of the facts to start the conversation. Commit however to following-up with more information.
  4. Take the time to plan appropriate, compassionate communication.

What should I consider reporting?

  1. Near miss – an error or unintended event that did not reach the patient or caused no harm. This is an opportunity to learn how to make care safer.
  2. Adverse event – an unexpected event that caused some harm to the patient or required additional action, even if temporary.
  3. Sentinel event – an unexpected event causing death or serious injury to a patient, or that could have done so, including “never events” like wrong site surgery, infant abduction, suicide while under medical care, etc.  All sentinel events must be immediately reported, so call someone.

How do I report near misses and adverse events at the different EUSOM affiliated hospitals?

Emory Healthcare

  1. The event reporting system is available as a link through the Virtual Desktop or through the Emory Healthcare intranet.
  2. Logon to Virtual Desktop https://www.emoryhealthcare.org/i-am/vdt-vdi.html
  3. Click the SAFE icon

Grady Health System

  1. The event reporting system is available as a link through EPIC.
  2. Logon to EPIC https://citrixnet.gmh.edu/vpn/index.html
  3. Click the RL6 icon

Children’s Healthcare of Atlanta (CHOA)

  1. The event reporting system is available as a link through EPIC.
  2. Logon to EPIC https://portal.choa.org/Citrix/portal/auth/login.aspx
  3. Click the ONS icon

The Atlanta Veterans Administration (VA) Hospital

  1. The event reporting system is available as a link through the Atlanta VA intranet or desktop.
  2. Logon to https://patientsafety.csd.disa.mil
  3. Click the JPSR icon

Who should I contact in cases of near misses or an adverse event?

Emory Healthcare

Always notify your attending and resident right away.

Notify a risk manager

  1. Call during weekdays: 404-686-2470
  2. Pager for the On-call 24/7 risk manager: pic # 50316
  3. The Trust Line allows for completely anonymous reporting through a third party that does not disclose information about you but passes event information to us: 1-888-550-8850.

Grady Health System

Always notify your attending and resident right away.

Notify a risk manager

  1. Call during 8am – 6pm: 404-616-4185
  2. After hours: call page operator 404-616-1000 and ask for on-call risk manager
  3. Director Angela King cell: 470-303-8510

Near miss hotline: 404-616-8600

Children’s Healthcare of Atlanta (CHOA)

Always notify your attending and resident right away.

Notify a risk manager

  1. In house phone x5-RISK
  2. Pager for the On-call 24/7 risk manager: 404-785-7475

Contact

  1. Sherry Bloomer 404-785-7462 or sherry.bloomer@choa.org
  2. Kelly Pelts 404-785-2357 or kelly.pelts@choa.org

The Atlanta Veterans Administration (VA) Hospital

  1. For Sentinel events, call the Patient Safety Office at x 4823
  2. To reach a risk manager – call x7409