Table 1. Summary of key findings – the current situation for reporting “unusual events” from hospitals, 
Viet Nam, 2016.

Key findings
Legal framework and standard operating procedures may play an important role in guiding reporting and response.	An enabling environment is necessary for timely reporting and response.	Potential benefits exist for the curative sector to work with the preventive medicine sector.	Health-care providers face multiple challenges to timely reporting.	Extra challenges exist for signal detection and reporting from remote areas and industrial zones.

SPECIFIC FINDINGS
Signal detection	Timely reporting	Rapid response
Challenges in detecting clusters despite awareness of “unusual events”   Although hospital and laboratory staff were sufficiently aware of what constitutes an “unusual event,” they were not aware of other similar unusual cases in other departments or other hospitals; therefore, they could not recognize clusters within the hospital.   An electronic reporting system may be one way to facilitate detection of clusters of similar cases through easy data sharing within the hospital.   Some doctors reported that the provision of information on disease trends in the locality might also help them be more aware. Unfamiliarity with rare infectious diseases can result in missed signals.   Some medical staff were not familiar with rare infectious diseases; therefore, they failed to detect signals or facilitate timely referral due to misdiagnosis. “Unusual events” were not considered signals for reporting until confirmatory diagnosis.   There was a misconception of the need to have a confirmatory diagnosis before reporting. Some doctors reported fear of being judged if the unusual event reported turned out to be not unusual.   With most provincial and district laboratories having insufficient capacity to perform the necessary diagnostic tests, doctors were hesitant to report “unusual events.”   Delayed laboratory results also decreased the incentive to send samples for confirmation to the provincial preventive medicine laboratories. Additional challenges to detect signals in rural areas   The situation was exacerbated in rural areas because of limited access to hospitals, fewer doctors trained in infectious diseases, limited laboratory capacity and cultural differences.	Supportive leadership and designated focal points were critical for timely reporting.   Although timely reporting was challenging in hospitals with a hierarchical structure, it was facilitated in other hospitals with supportive leadership. Overall, reporting systems worked best in hospitals with a designated focal person and backup focal persons assigned for reporting. Minimal ownership of reporting tasks among hospital staff   Following the introduction of Circular 54, which transferred the reporting task from the preventive medicine sector to the curative sector, some hospital staff have yet to fully accept this change.   Medical doctors were reluctant to report “unusual events” as they were not familiar with this activity and found it complicated and time-consuming. In addition, the reporting procedure was unclear in some hospitals. Unidirectional reporting reduced incentives to report.   Some hospital staff felt reporting to the preventive medicine sector was mostly a one-way relationship. A lack of feedback from the preventive medicine sector can decrease their incentives to report.   Timely reporting was seen in hospitals with close links to the preventive medicine sector and regular two-way communication.   Rapid response from the preventive medicine sector after receiving a report also enhanced the hospital staff’s desire to report. Extra difficulties for reporting from rural areas and industrial zones   Some areas, especially industrial zones, may not report because of the lack of or unclear reporting requirements/enforcement, and fear of economic ramifications.	Designated 24/7 focal points in the preventive medicine sector can facilitate rapid response.   Focal points assigned in the preventive medicine sector to receive reports from hospitals can facilitate rapid public health responses.   It is ideal to appoint backup focal points when focal points are not available so hospitals can report 24/7. Rapid response from the preventive medicine sector can build trust and a collaborative relationship between the two sectors.   Rapid response is not possible unless the preventive medicine sector is informed of possible public health events in a timely manner.   However, once reports are received, rapid response from the preventive medicine sector can also help hospital staff to see the value in timely reporting, thus improving their attitude and cooperation towards reporting.