Adverse safety events occur every day, and many of them lead to serious harm. They affect patients across entire health systems. In hospitals, doctors and nurses face constant demands on their time, and reporting incidents can easily fall to the bottom of the list. But the ability to collect and analyze this data is crucial for preventing future harm and improving patient safety.

A 2025 report from the HHS Office of Inspector General found that hospitals failed to capture more than half of patient harm events among hospitalized Medicare patients. In many cases, staff did not recognize an event as harm. In others, hospitals used narrow definitions that left events out of the reporting system entirely.

The problem often runs deeper than definitions. Staff may fear consequences for reporting safety events. Some reporting processes are so complicated and time-consuming that people give up, despite good intentions. And in many cases, the biggest barrier comes after a report is filed: hospitals fail to act on the data or share results with staff, leaving people wondering whether reporting made any difference at all.

Why Event Reporting Matters

The stakes are high. A September 2025 OIG report found that patient safety challenges have grown more complex, with persistent barriers including inconsistent harm definitions across hospitals, uncertainty about legal protections for reporting, limited patient and family involvement, and the underuse of newer technologies like AI.

Despite nearly 20 years of nationwide improvement efforts, patient harm rates in hospitals are not decreasing accordingly. Even seemingly minor events can cause serious harm. The Joint Commission’s 2023 Sentinel Event Data found that patient falls were the most frequently reported sentinel event, driven largely by failures in communication, teamwork, and following established policies.

What Strong Reporting Requires

The Patient Safety Network’s Patient Safety Primer outlines what every strong reporting process needs:

A supportive environment that protects the privacy of staff who report events.
Broad participation across all types of personnel.
Timely sharing of event summaries.
A structured way to review reports and build action plans.

With a cultural shift and the right healthcare risk management system, hospitals can increase reporting and see real improvements in patient outcomes.

Create a Positive Safety Culture

Reporting often carries a negative association. Many healthcare workers worry that speaking up about a mistake will cost them their job or damage their unit’s reputation. That fear keeps incidents hidden and prevents organizations from learning. Shifting to a positive reporting culture means moving away from blame and toward learning, so staff feel supported when they raise concerns. A few key steps can help hospitals get there.

1. Involve Executive Leadership

Culture change starts at the top. Hospital leaders should review their existing patient safety programs to make sure they do not discourage reporting, prohibit retaliation against staff who report incidents, and train managers on how to communicate these standards.

Leaders also need to show their commitment, not just state it. When senior leaders personally review incident reports and make that visibility known to staff, it signals that reporting is taken seriously at every level. Regular executive walk rounds reinforce this further, giving leadership a chance to ask frontline teams directly about safety events, near misses, and contributing factors.

2. Prioritize Teamwork Training

Staff who communicate well and work as a team are more likely to speak up and report incidents. Research on teamwork training shows it builds stronger communication skills and a more cohesive environment, creating an atmosphere where all personnel feel comfortable raising concerns.

The Veterans Administration piloted a program called Medical Team Training in 43 hospitals. A study published in JAMA found an 18% reduction in annual mortality at VA sites that completed the training, compared to 7% at sites that had not yet trained. The VA attributed this improvement to the team-focused culture the training helped create.

3. Shift to a Near Miss Focus

Viewing patient safety reporting as data collection, rather than error tracking, is a powerful shift. These data points are called leading indicators, and they are essential for identifying risks before they cause harm.

Near miss reports are some of the best leading indicators available. But hospitals consistently underuse them. Research confirms that near miss underreporting is widespread across healthcare settings, driven by fear of blame, poor feedback loops, accessibility barriers, and a perception that reports lead to no real change.

Encouraging near miss reporting requires changing how staff think about it. If near miss reports help identify preventable future incidents, then those reports have a beneficial value instead of a punitive one. This incentivizes more reporting, since additional data points increase the potential of finding new root causes.

Without near miss data, it is nearly impossible to build a true learning culture. When fear and friction get in the way of reporting, the real casualty is the chance to learn from what went wrong and prevent it from happening again.

4. Establish Tangible Benchmarks and Rewards

Staff recognition is a key ingredient in a positive safety culture. Leaders should regularly acknowledge those who identify unsafe conditions or suggest improvements to care processes, and share that recognition widely.

Children’s National Health System in D.C. built a full program around this idea called 10,000 Good Catches. Hospital leaders celebrated reporting through one-on-one outreach, a monthly Reducing Harm Hero recognition, and the awarding of “Zero in on Zero Harm” pins. The program increased safety event reports from 4,668 to more than 10,000 in three years.

Simplify the Incident Reporting Process

Making it easier to report is just as important as changing the culture. Doctors and nurses cannot always step away from a patient to file a report. When the process is slow, confusing, or overly long, they often skip it. Having a healthcare risk management system is a good start, but choosing one that truly streamlines reporting is what drives real improvement.

The right system should offer:

Increased efficiency

Long, generic forms with irrelevant questions slow people down and lead to incomplete or rushed reports. A system with configurable forms, conditional questions, drop-down menus, and auto-populated fields reduces the burden on staff. Less time filling out forms means more time with patients and fewer reporting errors.

Options for submitting reports

Some staff prefer to report anonymously to avoid any risk of blame. Others want to stay involved as a report moves forward. The VA keeps reporters identified during the root cause analysis so they can receive updates and contribute to findings. The FAA uses a similar approach, collecting identifying information upfront and then de-identifying reports afterward. Origami Risk supports both options, giving staff the ability to choose what works best for them.

Accessible reporting

Reporting should be possible anywhere, at any time. Origami Risk allows staff to submit reports through an intranet portal on a desktop or a mobile device. Capturing information right when and where an event happens improves ac...

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