Tag: Near Miss

How hospitals can increase patient safety event reporting

A hospital incident reporting system in hospitals helps increase patient safety event reporting, and in turn increases patient safety.

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.

read more

RMIS tricks to avoid your own Groundhog Day

Another Groundhog Day has come and gone. Or has it?

In the movie Groundhog Day, weatherman Phil Connors (played by Bill Murray) is forced to relive the same day, over and over again, no matter how he tries to change the outcome. The Environmental, Health and Safety Newsletter recently compared the latest release of the Census of Fatal Occupational Injuries with previous years and observed a similar phenomenon.

The article notes, “The latest census is remarkably consistent with the previous reports. People continue to die in numbers, proportions and circumstances much as they did the year before, and the year before that and the year before that. There are a lot of Groundhog Days in how we’re getting killed on the job.” Even worse is the fact that these factors are no secret. “The same hazards keep killing workers,” the article continues. “What’s most likely to kill someone is not a trick question. It’s an open-book exam.”

If something as critical as lowering workplace deaths can get trapped in an endless cycle of no progress, it shows just how immovable some of these challenges can be. Lack of desire or effort isn’t always to blame.

read more