The system either provides a redundant mechanism in a system that is already error-free, or it provides the anonymity that encourages wider disclosure of errors people already know about, or it provides a formal mechanism that assists people in the detection and articulation of dangerous but ambiguous moments in patient care. This paper cannot address questions regarding the levels or degrees of errors in the system. However, it can offer insight into both the importance of anonymity and the complexity of recognizing errors. The importance of anonymity is suggested by the following pattern. Complexities associated with the recognition of errors are suggested by the following patterns.
Respondents seem to be unsure of the types of errors that occur in their facilities.
This inability to identify sources of errors could be interpreted in at least two ways. If this interpretation is accurate, then it may be difficult to convince administrators and staff that a close call system would be beneficial. But, there is an important second possibility. Administrators and staff may be unsure of the origin of errors in their facility because they do not receive feedback or information about them. This second interpretation would help to explain uncertainty regarding whether errors involve patients.