Are staff reporting potential errors?
December 1, 2005 3 minutes read
Are staff reporting potential errors?
Include near-miss events in reporting
Your organization probably has a very small number of serious adverse outcomes, but in all likelihood, "near-misses" are very common, says Richard J. Croteau, MD, JCAHO’s executive director of patient safety initiatives. "We encourage organizations to include a broad range of events in their reporting systems — broader than what we require," he says.
Johns Hopkins uses an online event reporting system to report both actual events and near misses, says Dana Moore, RN, MS, a coach at the Baltimore, MD-based Coach for Center for Innovation in Quality Patient Care.
Anyone with access to a public workstation, which are located in every patient care area and also the pharmacy, lab and diagnostic testing areas, can report an event electronically. This automatically generates a notification alert to whoever is "mapped" to that particular event, says Moore.
For example, if a medication error occurs in a medical ICU, the nurse manager, pharmacist and educators are automatically e-mailed about the event. "Physicians also get alerted," says Moore. "It is a great system to allow for real-time notification of events, which leads to quicker follow-up."
The manager of the unit then electronically completes "a mini-root cause analysis," says Moore. "It asks what contributing factors were associated with the error and what follow-up was done," she explains. "The system also allows for tracking and trending."
The Hanover-based Maryland Patient Safety Center has designed a voluntary reporting system for health care providers to report near-misses that do not result in permanent harm to the patient. The system mirrors those currently in use by commercial aviation industry, says William F. Minogue, MD, FACP, the Center’s director.
The web-based software is currently being piloted in several Maryland hospitals, and serves as a comprehensive event reporting system. "The reason for collecting information about close calls is that they best reflect defects in the systems and process of care," says Minogue. "We will use that information to direct education and collaborative efforts, to see which processes need to be re-designed."
This information will supplement the mandatory reporting of serious adverse events already being collected by the state, says Minogue. "Each hospital will determine whether they want all reports to come to one central person or system within the organization, or allow the employees to report to us directly," he adds.
Staff must be convinced that error reporting will be used to improve care as opposed to punishing individuals, says Minogue.
At organizations which have done this, error reporting has increased dramatically, says Minogue. "It’s gone up exponentially — tenfold at some hospitals," he says. "Once the trust is built in, it starts to work. Employees must be able to trust that it won’t be used against them."
By reporting near-miss events, system problems can be detected before errors reach the patient, says Tootie Lunsford, RN, quality outcomes coordinator at Inova Loudoun Hospital in Leesburg, VA. "Since employees can enter near-miss events with the electronic system, our event reporting has increased. We did not do this with the paper system," she says. "Our hope is with increased reporting of near-miss events, that our actual events will decline."
Your organization probably has a very small number of serious adverse outcomes, but in all likelihood, near-misses are very common, says Richard J. Croteau, MD, JCAHOs executive director of patient safety initiatives. We encourage organizations to include a broad range of events in their reporting systems broader than what we require, he says.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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