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The PMMRC reported 227 infants with NE in the same time period, of whom 179 survived (table 1). Table?1 A summary of maternal and perinatal morbidities and mortalities reported as SAEs to the HQSC and to the PMMRC Discussion This report has compared maternal and perinatal SAEs reported to the HQSC with those reported to the PMMRC over the time period 2009�C2012. The purposes of the PMMRC and HQSC SAE reporting differ. They are bodies with different aims and processes. However, despite their differences, they both hold the common goal of improving care.12 With this in mind, it is reassuring that the PMMRC has identified and reported all the maternal and perinatal cases within the SAE reports that fall under PMMRC and AMOSS reporting definitions. There are, however, significant numbers of cases of maternal and perinatal mortality and morbidity that appear to fulfil the definition of SAE that have not been reported to the HQSC. The purpose of the SAE reports is ����to provide transparency, and improve the quality and safety of our health and disability services.����1 13 The Commission's national reportable events policy sets out a process for ensuring that SAEs are reviewed appropriately by the provider organisation, and subsequently reported to the Commission.9 The latest report notes that comparing data between years is problematic because more events are being reported and reviewed each year. It also recommends that the data should not be used to measure safety because there is considerable variation in the rates of reporting as well as the provision of services and the size of the community that each DHB serves. The clinical lead for the commission has stated that ����accurate information and analysis helps the health sector understand the extent and type of patient harm occurring.����14 The WHO has published guidelines for implementing effective reporting systems, outlining its core concepts: to enhance patient safety by learning from failures, ensuring reports are handled in a non-punitive manner, that reporting is followed by a constructive response with feedback, and that there is a meaningful analysis and dissemination of lessons learnt with recommendations for changes.15 Despite this transparent approach, there remains a recognised problem with local and national incident reporting systems.16 These problems include fear of punitive action, poor safety culture in an organisation, lack of understanding among www.selleckchem.com/products/EX-527.html clinicians about what should be reported, and how the reports will ultimately impact on patient safety.16 It has been identified by a similar patient safety organisation in England and Wales, the National Reporting and Learning System, that organisations reporting low numbers of patient safety incidents are often reporting these events locally, but not nationally.