Date of Paper/Work


Type of Paper/Work

Doctor of Nursing Practice Project

Degree Name

Doctor of Nursing Practice



First Advisor

Matthew Byrne


Doctor of Nursing Practice


Background: To reduce preventable medical errors, event reporting systems (ERS) are recommended error prevention tools to improve patient safety and high reliability in healthcare. Patient Safety ERS identify safety hazards and help mitigate risk and eliminate preventable harm to zero.

Problem: There is a delay in reviewer’s obtaining system access to the safety event reporting system (ERS) preventing safety event awareness, follow-up, and closure of patient safety events within the recommended best practice of 15 days. In current state, it takes an average of 132 days for a new leader to gain access to review and address patient safety events. This is 132 days where a similar patient safety event could impact another patient in the system. The lack of access threatens the safety of our patients and staff, resulting in inefficiencies in the system patient safety event management process and potential prevention of a similar event.

Interventions: This project aims to reduce the time it takes for a reviewer to have access to the ERS, by implementing three improvements. The three improvements include the development of a new Advanced Access Request (AAR) submission form, a new AAR approval process, and a new AAR submission process.

Results: Post implementation results were statistically significant in both process and outcome measures.

Conclusion: A standardized advanced access submission process to a patient safety event reporting system is recommended to ensure timely access to patient safety events.

Available for download on Saturday, August 02, 2025