Unreported incidents leading to claims indicate a weak reporting culture, requiring a focus on encouraging reporting to identify and mitigate risks.
Option A (Conduct retrospective medical record reviews to identify elements of risk): Reviews may identify risks but do not address the root issue of unreported incidents.
Option B (Implement a back-up paper process to the electronic reporting system): A paper process is unlikely to improve reporting culture and may complicate systems.
Option C (Identify options for a new electronic reporting system): A new system may help but is premature without addressing cultural barriers to reporting.
Option D (Create an organization-wide program that promotes reporting): This is the correct answer. The NAHQ CPHQ study guide states, “A non-punitive reporting culture, promoted through organization-wide programs, is essential to ensure incidents are reported and risks are identified” (Domain 1). Programs include training and incentives to encourage reporting.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.2, “Promote a culture of safety,” emphasizes fostering reporting. The NAHQ study guide notes, “Programs to promote reporting are critical when incidents are underreported” (Domain 1).
Rationale: Promoting reporting addresses the cultural barrier causing unreported claims, aligning with CPHQ’s safety culture principles.
[Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.2., , , , ]
