Effective error reporting: Quality leaders share cutting-edge strategies
It’s not enough to identify adverse events — they must be analyzed
Are dangerous errors going undetected at your organization? Or are some types of errors being carefully tracked, but without action taken to prevent similar mistakes?
You may be the deciding factor in whether the problem is addressed.
"Hospital CEOs are often aware of safety problems and committed to improve them but don’t know what to do and are often afraid to say so," says Peter J. Pronovost, MD, PhD, medical director at the Baltimore-based Center for Innovations in Quality Patient Care at Johns Hopkins University School of Medicine. The goal is to ensure that safety problems are not only identified but effectively addressed, he stresses.
In the recently published Healthcare at the Crossroads, JCAHO recommends that organizations improve error reporting systems to reduce liability risks and increase safety. In addition, the recently passed Patient Safety and Quality Improvement Act of 2005 will encourage organizations to report errors to patient safety organizations.
As for internal reporting within the organization, JCAHO surveyors want to see effective systems in place to identify, report, and analyze adverse events. "Most of the safety-related requirements get high priority on survey, and error reporting is certainly one of them," says Richard J. Croteau, MD, JCAHO’s executive director of patient safety initiatives.
Organizations will be asked to define what events they consider reportable and to have systems in place to ensure that reported events are analyzed.
"One thing that comes up and is truly a red flag is when you hear We don’t have any problems. We haven’t had any sentinel events,’" says Croteau. "That’s either flat out denial or a totally inadequate process for recognizing when things are going wrong. Our surveyors are tuned into that and will start looking more deeply into the culture of the organization. Do they have a reporting system? If they do, why isn’t it being used?"
Surveyors will ask about your processes for root cause analysis and ask for examples of how adverse events were reported and analyzed.
"If we have been aware of a sentinel event in that organization and have worked with them on a sentinel event policy, then we may inquire as to how they’ve evaluated their action plan and whether it’s working," says Croteau.
The JCAHO has proposed revisions to its leadership standards that will assess whether an organization has a "culture of safety," with specific requirements that will be surveyed. Error reporting will be a major focus, says Croteau.
Feedback from the field on the draft standards currently is being analyzed, and the approved standards will become effective sometime in 2007.
"This is quite a big step, actually," says Croteau. "A few years ago, we proposed standards that talked about culture of safety, and people were very uncomfortable with that. I think it’s a good indicator of the movement that we’ve seen in the last several years, that people are now eager to have that built into our standards."
The new JCAHO standards would require all organizations to do a self-assessment with an evidence-based tool such as the Agency for Healthcare Research and Quality’s Hospital Survey on Patient Safety Culture or similar tools such as those developed by the Stanford Hospital & Clinics or the Veterans Administration’s National Center for Patient Safety.
The development of survey instruments to assess organizational culture is a turning point, because this is now a measurable goal, Croteau adds. "The idea of culture is hard to get your arms around. But they have come up with a good idea of the characteristics of a safety culture and we can now assess them," he says.
Organizations increasingly are using software to facilitate error reporting, identify patterns, and monitor corrective actions, Pronovost notes. Pronovost developed the Comprehensive Unit-Based Safety Program (CUSP) in 2001 at Johns Hopkins Hospital, to create a culture that targets system failures and not individual fault.
An electronic version (eCUSP) recently was developed by the Boston-based Patient Safety Group as a tool to identify safety concerns and monitor, record, and share safety interventions to prevent future errors.
"Certainly technology can help, because it makes it easier for people to report. It also helps the process of analyzing the reports," says Croteau.
Patient safety software can give you the data and ammunition you need to direct change, adds Jay King, executive director of the Boston-based Patient Safety Group.
At Northern Michigan Hospital (NMH), the medical/surgical intensive care unit (ICU) uses an electronic system to address patient safety concerns, manage patient safety issues and projects, and report to the hospital’s patient safety team, integrated performance improvement council, and board of trustees. "This has dramatically improved the culture of safety at our organization," says Gretchen Schrage, MBA, manager of performance improvement and patient safety.
Here are several "fixes" for patient safety concerns reported by NMH staff:
- To reduce complications with stents for patients receiving antiplatelet medication, a simple change in the preprinted physician order form prevents patients from missing the loading dose or getting duplicate loading doses.
- To avoid problems with endotracheal tube stability and airway protection, all patients are retaped on arrival to the ICU, regardless of expected time to extubation.
- To address lack of access to point-of-care testing, an organizationwide schedule was created for every nursing unit to complete all required competencies. This resolves communication issues between lab and nursing and ensures regulatory compliance.
"The program provides complete project management capabilities for our ICU patient safety team," says Schrage. "We now have a data-driven process, a mechanism to help close the loop’ on all issues and projects, and educational opportunities to learn from our defects."
At Inova Loudoun Hospital in Leesburg, VA, an electronic system is used to report errors, with improved accountability since follow-up must be completed, says Tootie Lunsford, RN, quality outcomes coordinator.
"Trending reports are phenomenal and are being used at the unit level to identify specific problem areas to focus QI activity," she says. Falls can be broken down by unit, shift, and category, such as bed to floor, chair to floor, or bathroom related. Staffing can be correlated to any increases in falls to see if adjustments need to be made.
The reports are also used to identify uncommon occurrences happening across multiple units, such as equipment failure, system error, or physician practice variance. "We have used trending reports to take an in-depth look at medication variances and our falls policy and protocol," says Lunsford.
The reports are easy to understand and can be customized to target audiences. For instance, reports involving nursing are received by the shared governance unit practice councils and the clinical effectiveness council, whereas the safety committee receives a report on events such as falls and specimen labeling variances.
"We also receive reports on use of unapproved abbreviations in medication orders, which are relayed to medical department chairs and the involved physician," says Lunsford. "We can identify a department’s interest and impact area and design a report to support that."
For instance, the ICU’s unit practice council has been looking at events linked to electronic medication administration records, such as transcriptions missed, errors in medication, dosage, or scheduling information.
"We can adapt reporting to follow short-term interest areas such as unavailability of supplies or IV phlebitis rates," she says. "I feel that this type of system is the future for us, to assure our patients’ safety," says Lunsford.
To improve error reporting at your organization, consider the following:
• Make it easy to report errors.
The problem with reporting systems is that they are always incomplete, says Croteau. "The easier and less threatening it is to report, the more reports you are going to get, and the better chance you will have of knowing what’s actually going on," he says.
There is a growing trend toward openness in error reporting, says Croteau. "I think it is happening more and more in health care. We still see a spectrum of responses to adverse events. But more organizations are realizing that they can get more benefit out of a non-punitive approach — with a systems analysis rather than a focus on individual behavior," he says.
When staff at Inova Loudoun report an event, they are given the option to do so anonymously. "We believe this results in more events being reported," says Lunsford.
Web-based systems give the frontline user an anonymous way to report a safety concern online, says Dana Moore, RN, MS, a coach at the Baltimore, MD-based Coach for Center for Innovation in Quality Patient Care, and clinical nurse specialist in the medical ICU at Johns Hopkins Hospital. "If a staff member does not feel comfortable voicing their concerns, they can easily go to the site and report the concern anonymously," she adds.
In addition, e-mail notifications can automatically be sent to staff to remind them to enter safety concerns or to update a project. "This is a nice feature. We are all busy and sometimes need a reminder to push us to action," says Moore.
• Work with valid data.
"A little knowledge is dangerous," says Pronovost. "Some organizations look at incident reports of medication errors and use that data as a valid rate of performance. But it’s likely biased and not informative as a rate. We can learn from the events, but we should not be monitoring rates of self-reported events."
The problem is that quality leaders become focused on submitting error reports, instead of learning from them, he says.
At Inova Loudoun, incident reports and follow-ups are electronically reported in one location, which results in better data. "There is no more lost paperwork or lost reports. Our paper report was very confusing to fill out, sections were left blank, and information was incomplete," says Lunsford.
As a result, it was difficult to generate any meaningful reports that people could understand and use, says Lunsford. "Senior administration is networked to be notified of major events as they happen," she says. "We don’t get incomplete reports, as mandatory fields must be entered to move on."
• Make sure there is accountability.
When staff concerns are reported, appropriate leaders must be identified and corrective actions implemented as needed, says King. "Projects can be led by anyone on staff, following the adage everyone is empowered to lead,’’’ he says.
At Inova Loudoun, reported errors are sent to unit managers to investigate, who then electronically document causative factors and preventative measures taken.
Events are also tracked by the nursing director, with a seven-day time limit for follow-up. A reminder e-mail is sent after 10 days to ask for documentation of completion. "If another department is also affected, it can be sent to them for follow-up as well, or to the risk manager if it was a serious event," says Lunsford.
• Involve unit staff.
To identify safety issues effectively, caregivers should answer the question, "How will the next patient in your work unit be harmed?" says King. "This is very different from asking staff to report errors. This picks up where that leaves off and then some," he says.
Most quality professionals could never have departments big enough to make care safe, says Pronovost. "It has to be lived by the people delivering care on the front lines," he says. "What we need to do is provide some structure to empower them to learn from mistakes."
At OSF St. Joseph Medical Center in Bloomington, IL, an electronic patient safety program is being used on a labor and delivery unit and a general medical unit, with 20 "quick fix" projects and one large project involving falls reduction. For complex safety issues, team members are assigned with reporting requirements and e-mailed directly so the sequence of events can be tracked.
"So a team member can go into the system, and do all the work related to the issue from the program," says Kathy Haig, director of quality resource management. "Use of the system is spreading to all nursing units in our efforts to spread the safety culture to the microsystem level."
As a result of a safety concern entered by staff, it was determined that incident reports didn’t give enough information for a good analysis of patient falls, so the staff created a report specific to falls and a program to identify patients at risk for falls. In addition to process changes, the project’s data prompted the purchase of equipment such as low beds, magnetic alarms and rubber mats, resulting in the fall rate decreasing by 50%.
"It’s everyone’s obligation to report safety concerns, and this gives them a quick, easy, user-friendly way to report," says Haig. "You don’t have to fill out a piece of paper."
The tool "spreads safety responsibility" to unit staff, adds Haig. "The patient safety officer can’t be in every room with every patient," she says. "And from a performance improvement standpoint, I can go onto the web site and show leadership, medical staff, or regulatory surveyors what each unit has identified as a safety concern and how it is being addressed."
• Enable staff members to see progress.
Technology can be an effective way to provide feedback to staff members who report concerns, says Croteau. "That is a characteristic of an effective reporting system. It is a real incentive for people to report, if they get information back and see that something is being done. If they don’t get that, they will stop reporting."
Too often, staff members may report a safety concern and never hear about it again, says Moore. By using the patient safety software, individuals can log onto the system and immediately see what progress is being made. "This alleviates the frustration staff feel when they voice a concern but then have no way to monitor the outcome," she says.
Project leaders are responsible for monitoring the progress of a safety project. "If they feel progress is moving too slow, they can help troubleshoot problems or motivate where needed," says Moore.
• Share fixes.
Units sometimes fail to share their successful strategies with other departments with similar problems. As problems are fixed, the patient safety software used at OSF St. Joseph turns them into "shared stories" that other hospitals can access. "Process changes are not always earth shattering. But little process breaks can make the whole system fail," says Haig. "This lets the staff member know that what they are doing is shared across the country. I think that sends a powerful message to staff on the importance of their input and involvement."
[For more information, contact:
- Kathy Haig, Director, Quality/Risk Management/ Patient Safety Officer, OSF St. Joseph Medical Center, Bloomington, IL. Telephone: (309) 662-3311, ext. 1347.
E-mail: [email protected]. - Jay King, Executive Director, The Patient Safety Group, Boston. Telephone: (617) 620-6320. E-mail: [email protected]. Web: www.patientsafetygroup.org
- Tootie Lunsford, RN, Quality Outcomes Coordinator, Inova Loudoun Hospital, Leesburg, VA. Telephone: (703) 858-6629. E-mail: [email protected].
- Peter J. Pronovost, MD, PhD, Medical Director, Center for Innovations in Quality Patient Care, The Johns Hopkins University School of Medicine, Baltimore. Telephone: (410) 502-3231. E-mail: [email protected].
- Gretchen Schrage, MBA, Manager, Performance Improvement & Patient Safety, Northern Michigan Hospital, Petoskey, MI. Telephone: (231) 487-7812. E-mail: [email protected].]
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