Patient Safety Reporting Systems are a commonly used method for capturing information about adverse events and near misses in the acute care setting. These event reports are almost exclusively submitted by the frontline care provider, and the patient perspective of the event is rarely captured. The authors present a case which illustrates the use of eliciting the patient's perspective to provide a complementary perspective to the provider's description of the event. The methodology for obtaining and using this information to enhance understanding of the event and to inform prevention strategies is described.
From the *Department of Quality Management, Johns Hopkins Bayview Medical Center; †Departments of Anesthesiology and Critical Care, Surgery,and Health Policy and Management, The Johns Hopkins University School of Medicine; ‡Department of Surgery, Cancer Research Bldg. II; and §Departments of Health Policy and Management, Epidemiology, International Health, Medicine, and Surgery, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
Correspondence: E. Anne Millman, MS, Director, Patient Safety, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, Baltimore, MD 21224 (e-mail: firstname.lastname@example.org).