[MUSIC] In this video, we're going to talk about what happens after an event is submitted. Often among staff, there's a perception that events go into a black hole. But that is not the case. When an event is submitted, it's entered into the database. Depending on your organization, your event may take several different pathways. Typically, an event routes based off the event type as well as the locations involved. For example, if an event is a fall on 4 South, the event will go to a falls committee as well as the local managers for that unit. An event may be addressed locally, where managers and other teams access the report. Local teams like CUSP teams may take interventions or put interventions in place to support local improvements. An event also may be read by a patient safety analyst, who reviews every single event report that is submitted. The patient safety analyst may forward the event to a task force. And the task force may then evaluate the event report and identify system changes that should be implemented to prevent the event from happening again. The system analyst also may convene a multi-disciplinary event review team themselves. And that review group may create additional action items to ensure the events from happening again. Typically, events that involve high harm are reviewed by Risk Management. Risk Management identifies high harm events, potential claims, and other events of interest. Risk Management evaluates trends and conducts root cause analyses. Risk Management also may prepare reports for regulatory agencies. Regardless of the path that the event takes, though, the idea is that system changes are put in place as a result of the events that are submitted. In addition, the learnings from these events should be communicated across the organization, and across the nation, where appropriate. Using the discussion board, describe the journey of an event report in your organization. How do you recommend overcoming barriers to reporting and learning from events? Some things you may want to consider is, how do you access the event reporting system in your organization? Is it on a computer desktop, or perhaps a SharePoint site? What managers review events? What committees or teams review events? How are changes implemented? Do harmful and non-harmful events have similar review processes? Are events or system changes shared across the organization? And are patients and families included in any event review processes?