Our event reporting tool is used by three principle stakeholders: Risk management, Performance Improvement, and Medication Safety. When documenting some recent events, we have become aware that the interests of these key stakeholders are sometimes at cross-purposes.

Risk management would like to see clear causation before making an assessment of harm. Their definition is quite conservative with an eye towards the legal risks and discoverability of the event review process. Their driving question tends towards, "Is our institution responsible for causing harm?"