Adverse safety events—some that lead to serious harm—occur every day, affecting people across entire health systems. The ability to collect and analyze this data is crucial for preventing future incidents and improving patient safety. Yet, according to a 2008 study, “only 13% [of U.S. hospitals] have broad staff involvement in reporting adverse events.”
With a full schedule of patients and life-or-death situations a part of daily life in hospitals, reporting efforts, not surprisingly, may end up taking a back seat. Sometimes, however, the issues that impact reporting run deeper. Hospital staff may fear repercussions from reporting safety events. In other instances, the reporting process may be so convoluted and time consuming that, despite good intentions, staff is discouraged from doing so. Or maybe, the biggest issue comes after reporting, with hospitals failing to share or apply healthcare analytics in a way that positively impacts the quality of care provided and makes staff feel a part of something bigger.
No matter the reason, any issue that negatively impacts patient safety event reporting has consequences for every person associated with a hospital or health system—especially the patients. In fact, the ECRI Institute listed “standardizing safety efforts across large health systems” as one of the top 10 patient safety concerns for 2019. Even events that seem minor have the potential to result in grave harm. The Joint Commission reported medication error and product and device events in the list of top 10 most frequently reported sentinel events in hospitals in 2018.
To address this issue, the Patient Safety Network’s Patient Safety Primer says every patient safety event reporting process should have the following attributes:
- Institutions must have a supportive environment for event reporting that protects the privacy of staff who report occurrences.
- Reports should be received from a broad range of personnel.
- Summaries of reported events must be disseminated in a timely fashion.
- A structured mechanism must be in place for reviewing reports and developing action plans.
By instituting a cultural shift and implementing an easy-to-use healthcare risk management system with reporting, automation, and healthcare analytics functionality, hospitals can boost staff reporting and see life-changing results for their patients.
Create a positive safety culture
The process of patient safety event reporting often carries a negative connotation. As former British Health Secretary Jeremy Hunt said at the 2018 World Patient Safety Summit in London, “People are terrified that if they’re open about what happens, they…might get fired by their hospital, and it’ll be bad for the reputation of their unit and their trust.”
Switching from a negative reporting culture to a positive one is essential. This means, Hunt says, “moving from a blame culture to a learning culture so doctors and nurses are supported to be open about mistakes rather than cover them up for fear of losing their job.” Here are a few steps hospitals can take to enact this cultural shift:
Involve executive leadership
A cultural shift must start at the top. The EHS Today article The Risks of Using Injury and Illness Reporting as Measurements of Success says hospital leadership should reexamine their existing patient safety programs to make sure they’re not incentivizing non-reporting, prohibit retaliatory actions against staff who report incidents, and provide training to workplace leaders to communicate these compliance measures.
Then they must show—not just say—that they’re fully invested in the patient safety event reporting process. Rahul Shah, MD, vice president, chief quality and safety officer at Children’s National Health System in Washington, D.C., provides a good example. “Staff members also know their incident reports are being reviewed at a senior executive level,” he told Health Leaders Media. “I read every incident report in the organization. I made that pledge about three-and-a-half years ago, when we had 4,000 incident reports. I still stand by that pledge when we have 11,000 incident reports.”
Senior leadership can also demonstrate their involvement through executive walk rounds (EWR). These weekly visits to different teams throughout the hospital allow them to ask staff about patient safety events, near misses, and any factors that may have led to adverse events. OSF St. Joseph Medical Center in Bloomington, Illinois, uses the WalkRounds™ concept, sending on-the-ground information directly to the highest levels of leadership for increased awareness and strategic planning.
Prioritize teamwork training
Hospital staff who know how to work well together and communicate effectively—in both routine and challenging situations—are more likely to raise concerns and report incidents. As the Patient Safety Network states, such training “focuses on developing effective communication skills and a more cohesive environment among team members, and on creating an atmosphere in which all personnel feel comfortable speaking up when they suspect a problem.” The Veterans Administration implemented a teamwork training program called Medical Team Training in 43 of its hospitals. A follow-up study showed a dramatic reduction in mortality within surgical units that had undergone the training compared to those that hadn’t. The VA found that the team-focused culture brought about by the training was essential to improving safety.
Shift to a near miss focus
An important component of making the mental shift from negative to positive is viewing patient safety reporting not as tracking errors, but as collecting data to inform measures of improvement. Known as leading indicators, these pieces of data are necessary for informing change and preventing future incidents.
In a hospital setting, near miss reports make exceptional leading indicators. However, a 2017 study in the International Journal for Quality in Health Care about attitudes toward incident reporting states that hospital staff are more likely to report severe events than near misses, at an odds ratio of 1.78. Hospitals must encourage near miss reporting by stressing how capturing this healthcare data is essential for harm prevention and meaningful change. As discussed in How to avoid the new OSHA culture penalty:
“If near miss reports help identify preventable future incidents, then those reports have a beneficial value (instead of a punitive one). This incentivizes more reporting, since additional data points (near miss incidents) increase the potential of finding new root causes.”
Without leading indicators, without near miss data, growth culture is impossible. Former health secretary Hunt puts it this way: “A thousand worries prevent the one thing that really should be happening, which is proper learning from that mistake and a proper attempt to make sure it can never be repeated.”
Establish tangible benchmarks and rewards
The article 10 steps for improving your hospital’s safety culture points to staff recognition as a key way to establish a positive safety culture. The article suggests that leadership “[r]egularly acknowledge those who identify unsafe conditions or make excellent suggestions to improve care processes, and share this information widely.”
To put this type of approach in place, Children’s National Health System in D.C. developed its own comprehensive program of positive reinforcement, called 10,000 Good Catches. As noted in Overcome 3 Challenges In Hospital Incident Reporting, hospital leadership celebrated staff for reporting incidents and near misses through “one-on-one outreach, naming a monthly Reducing Harm Hero, and the awarding of ‘Zero in on Zero Harm’ pins.”
Simplify the incident reporting process
A major part of increasing patient safety event reporting comes down to simplifying the reporting process itself. The urgent nature of doctors’ and nurses’ jobs means stepping away isn’t always an option, leading them to overlook reporting. An overly complicated, time-consuming, and restricted incident reporting process further decreases the likelihood of reporting. So although having a healthcare risk management system at all is a great first step, hospitals will see a real boost in reporting by going a step further and implementing one that streamlines and simplifies the process.
The right healthcare risk management software should allow for:
Many hospital incident reporting processes involve far too much manual data entry—and too much muddling through long forms that contain questions not applicable to a staff member’s specific unit or department. This takes up time and leads to distracted, rushed, and inaccurate reporting. A healthcare risk management system with configurable patient safety event reporting forms that include elements such contingent questions, drop-down lists for code selection, and dynamic field population can reduce data entry errors and cut down on the amount of time staff is away from patients and other urgent matters.
Options for submitting reports
Anonymous reporting offers both benefits and challenges. Making an incident report anonymously can remove some fear of blame, which can lead to more healthcare data and more honest healthcare data. But given the personal nature of the staff-patient relationship in hospitals, employees may, conversely, prefer direct involvement in the progress of an incident they have reported. Staff at the U.S. Department of Veterans Affairs, for example, “are asked to report safety events to their facility’s patient safety manager. The employee who makes these internal reports remains ‘identified’ until the root cause analysis is completed so that the employee can be notified of and comment on the findings.”
The Federal Aviation Administration has a reporting system that asks employees to identify themselves upon submitting an incident so they can be contacted in the event that more information is needed. But “the reports are subsequently ‘de-identified,’” protecting employees’ anonymity until that time. Origami Risk’s incident reporting functionality has the option for making a report known or anonymous, giving hospital staff options based on their personal preference.
To increase reporting, hospitals can benefit from a healthcare risk management system with broad accessibility. Origami Risk’s healthcare risk management software allows for reporting via an intranet portal on desktop or via mobile device. This allows staff to capture healthcare data when and where a patient safety event occurs, adding convenience and increasing accuracy. Furthermore, as stated in How to create a successful and sustainable near-miss culture, “The ability to input incident and near miss data while in the field can be a critical part of the process…Mobile reporting reduces lag time and helps investigations begin faster.” The sooner an incident gets reported, the sooner that data can lead to patient aid and organizational change.
Improve healthcare analytics and communication of incidents
To increase patient safety reporting, hospitals must be equally proactive after incidents are reported. This means alerting the necessary parties, strategically analyzing aggregated healthcare data and, finally, sharing the end results with staff. According to The Patient Safety Primer, however, many hospitals do none of the above. The error management study referenced above notes that “most hospitals surveyed did not have robust processes for analyzing and acting upon aggregated event reports” and only “20–21% [of hospitals] fully distribute and consider summary reports on identified events.”
This discourages employees from reporting in the future, as they see no evidence that doing so makes a difference.
Hospitals can make following up on reports a priority by:
Setting up automated alerts/messages
The first step in developing real change comes by alerting key parties after a patient safety incident has been reported. The article How to create a successful and sustainable near miss culture states, “The worst-case scenario is near miss reports that appear to go into the organizational black hole, never to be seen or heard about again.” With a healthcare risk management platform like Origami Risk, hospitals can set up rules-based automation that fires off alerts and messages to the appropriate people for swift action and increased accountability.
As an incident report progresses, the employee who reported the patient safety event in the first place can receive automated updates. After the data undergoes healthcare analytics (see below), the same employee can see how exactly his or her incident report helped move the needle. As the Patient Safety Primer says: “Failure to receive feedback after reporting an event is a commonly cited barrier to event reporting by both physicians and allied health professionals.”
Using healthcare analytics
With automation—and automated communication—in place, hospitals can set their sights on the bigger picture. They can effectively turn data into insight, analyzing the incidents in order to see trends and spot outliers. Origami Risk uses several root-cause methodologies—including fishbone, RCA2, and the 5 whys—to help make better strategic decisions and enhance program quality.
Sentara Norfolk General Hospital in Virginia recognized the importance of healthcare analytics in creating organization-wide change. One of the four strategies it has adopted to improve patient safety is:
“Improve the staff’s ability to conduct timely and rigorous ‘root cause analysis’…of major safety events, such as by identifying the common contributing causes of a series of events, so that these analyses identify long-lasting, systems-oriented change.”
When hospitals are able to dive deeper into data and implement corrective actions that bring about noticeable change/improvement, staff see the full impact of their reporting activity. As a result, they are encouraged to continue contributing to a patient safety and learning culture.
Origami Risk’s healthcare risk management software helps encourage patient safety event reporting
Increasing incident reporting is no small feat. The key lies in a cultural shift that starts at the top and makes its way through the entire organization. This can be paired with healthcare risk management technology that’s capable of streamlining the patient safety event reporting process, communicating report details to the appropriate people, and using healthcare analytics in a way that leads to noteworthy change. Origami Risk’s flexible, simplified healthcare risk management software delivers the best-practice tools you need to see an increase in reporting and an improvement in patient safety.
Find out how Origami Risk’s healthcare risk management software can help your organization increase its patient safety event reporting. Speak with a member of our healthcare team today!