Introduction: Medical errors are among the leading preventable causes of patient mortality in hospitals. At imam reza hospital complex, with approximately 60,000 inpatient admissions annually, the occurrence of only 22 life-threatening codes per year indicated an inefficient mandatory and voluntary reporting system. Accordingly, this study was conducted to improve the management of reporting and feedback of life-threatening events within the domain of patient safety.
Methods: The present study was an action research conducted using a mixed quantitative-qualitative approach and implemented in four stages in 2023. In the first stage, the dimensions of the problem were identified, and initial advocacy was undertaken with an emphasis on key stakeholders. In the second stage, design and planning were carried out in four phases. The third stage focused on stakeholder engagement for implementation, with involvement of a broader range of stakeholders. In the fourth stage, the final implementation framework, evaluation results, and necessary actions for sustainability were completed.
Results: The life-threatening event management system was structured around eight core dimensions. These dimensions did not function linearly or independently; rather, they formed a dynamic and interconnected cycle. The process began with clarification of objectives and identification and training of users, followed by event documentation and reporting within the hospital’s policy framework. Reported events then entered the evaluation and root cause analysis (RCA) phase, and the findings of rca were communicated to managerial and operational levels through structured feedback mechanisms. Finally, sharing the findings led to refinement of training programs, revision of policies, and redefinition of objectives, thereby continuously repeating and strengthening the life-threatening event management cycle.
Conclusion: The proposed framework is not merely an operational tool for event reporting but a systemic intervention aimed at enhancing patient safety. By integrating governance structures, technical processes, and cultural considerations, this framework creates the conditions necessary for organizational learning, reduction of recurrent errors, and sustainability of safety improvements. Its implementation can serve as a transferable model for other healthcare centers and provide a foundation for evidence-based policymaking and decision-making in the field of patient safety.