ABSTRACT
After two unexpected deaths, system-wide changes to safety management were made in the Calgary Health Region. These included development of a new reporting system to replace incident reports. The new ‘safety learning reports’ focus on what happened to the patient: was the patient harmed or nearly harmed? The latter, representing close calls, are valuable sources of information about hazards and hazardous situations, for both patients and healthcare providers. Immediate safety reviews can be initiated by the reporting of both close calls and untoward events. Reporters are encouraged to describe ‘what saved the day’, as well as make recommendations for system improvement.
