Skip to main content

Closing the Loop: Follow-up and Feedback in a Patient Safety Program

Buy Article:

$12.00 plus tax (Refund Policy)


Background: As health care organizations establish patient safety agendas, attention has focused on creating less cumbersome systems for reporting errors. However, experience at Brigham and Women's Hospital (Boston) suggests that more emphasis needs to be placed on what happens after a report is submitted.

Follow-up and Feedback: Follow-up includes prioritizing opportunities and actions, assigning responsibility and accountability, and implementing the action plan. Feedback entails (1) follow-up to those who report issues and (2) communication to the hospital staff and clinicians about events and actions taken. Responsibility and accountability for improvements need to be assigned by senior administration to hospital leaders who can effect the needed changes. Hospital leaders, not just the members of the patient safety team, must own these changes or improvements. Events that require follow-up action are brought to the attention of risk management and the patient safety team through several mechanisms, including voluntary reporting of adverse events through a computerized safety reporting system, root cause analyses, and Patient Safety Leadership WalkRounds.

Discussion: Developing and maintaining a systematic method for feedback represents more of a challenge than the completion of any single recommended action item. However, it is the feedback to the reporter that perpetuates the influx of information and closes the loop. Developing the information-tracking database has made providing feedback easier and more reliable but significant effort is required to keep the database current.

Document Type: Research Article

Publication date: 2005-11-01

More about this publication?
  • The Joint Commission Journal on Quality and Patient Safety will be published by Elsevier beginning in 2017! For readers who receive access to the journal through their institutions, the journal can now be found on ScienceDirect ( For librarians looking to subscribe to the journal for their institutions please contact your Elsevier Account Manager or visit for more information. All other readers, please visit to subscribe to the journal or to claim your access for an existing subscription.
  • Editorial Board
  • Information for Authors
  • Subscribe to this Title
  • Information for Advertisers
  • Reprints and Permissions
  • Index
  • Ingenta Connect is not responsible for the content or availability of external websites
  • Access Key
  • Free ContentFree content
  • Partial Free ContentPartial Free content
  • New ContentNew content
  • Open Access ContentOpen access content
  • Partial Open Access ContentPartial Open access content
  • Subscribed ContentSubscribed content
  • Partial Subscribed ContentPartial Subscribed content
  • Free Trial ContentFree trial content
Cookie Policy
Cookie Policy
Ingenta Connect website makes use of cookies so as to keep track of data that you have filled in. I am Happy with this Find out more