Hospital Improves Responses to Adverse Events and Near Misses
February 1, 2025 5 minutes read
By Greg Freeman
Executive Summary
A hospital encourages open reporting of adverse events and near misses to improve the culture of safety. Staff making notable reports are publicly praised.
- The hospital studies the ratio of near misses and adverse events reported.
- Staff must have no fear of punishment when reporting.
- Summits with law enforcement help address violence in the hospital.
An Illinois hospital has improved patient safety by implementing a program that encourages reporting of adverse events and near misses. The hospital also encourages staff to report positive experiences that affect the culture of safety and promotes those stories.
In 2019, Springfield (IL) Memorial Hospital revised its statement of values to make safety the first priority and encourage a “Safety First” culture, says Vice President and Chief Quality Officer Lance Millburg.
One component of the effort is the Great Catch program, which is intended to catch safety gaps before they reach patients or staff. An electronic event reporting and management system called System for Event Notification to Support Organizational Reliability (SENSOR) helps the hospital learn from actual and near-miss events, Millburg says.
All employees are encouraged to share both positive stories of safety practices being maintained as well as incidents of concern, he says. Springfield Memorial shares those stories with the rest of the hospital staff to encourage more reporting and demonstrate positive feedback.
“Having a strong reporting culture is super important for you to be able to learn about where there are gaps in quality of care. Ensuring that you can monitor trends helps you pick up on the subtle changes in outcomes,” Millburg says. “We’ve built our SENSOR reporting system into the medical record in a way where you can click on a link and if you know something happened or you notice something that you want to report, you can just click it right there. It opens up and colleagues are able to put information in.”
Key to the success of the reporting system is employees having no fear of retribution, Millburg says. If staff think they might face any sort of punishment, the program will fail, he says, so an organization-wide culture of safety is paramount, he says.
“The reporting culture is almost indicative of the culture of safety that you have is, it’s kind of a litmus test to how safe colleagues feel with bringing things forward, where sometimes it’s even themselves that have made the mistake that they’re bringing forward,” Millburg says. “But one of the things that we’ve done in order to help us advance this — it’s almost necessary, if not required — is to make sure that you’re a part of the patient safety organization [PSO].”
The PSO provides legal protections so staff can feel safe to share information without fear of reprisals, Millburg says.
Watching Near-Miss Events
The Great Catch program emphasizes the value of reporting near-miss events as well as issues that reached the patient or employee and caused harm, Millburg says.
“There are different levels of harm, ranging from a near-miss that we consider a precursor event, meaning it never really reached the patient. This would be something like walking in a room and maybe a sharp is sitting out on the desk, hasn’t hurt anybody, but it’s an unsafe condition. If that starts to happen a lot, there’s a higher likelihood someone’s going to get a sharp injury,” Millburg says. “We monitor that and we call it the Great Catch ratio, which is essentially precursor events divided by your harm events. We want that to be as high as possible. We actually want there to be more precursor events reported to us than anything that actually reaches the patient.”
The Great Catch award is a way to recognize staff who go above and beyond to fix or mitigate a patient safety situation, Millburg says. The award could stem from recognizing that when they open the Pyxis drawer that a med is in the wrong drawer, he notes, or realizing that a provided medication does not align with the verbal expectations that have been talked about with the care team.
“We’ve had situations where we’ve avoided giving patients anticoagulation in an unintended way. We actually comb through our record on a daily basis of these events that come in and sometimes leaders will want their colleagues recognized. A lot of times a patient team will see something that was put in and say, ‘Wow, that was a great catch,” Millburg says. “Then we go out and we celebrate it with them. We come up with a certificate, and we’ll set up a time, and we get the team together, take a picture and have a moment of celebrating the great work.”
The hospital saw an increase in reporting after implementing that recognition.
“I think colleagues got excited and they wanted to also be recognized,” he says. “It really increased the amount of information that we had to analyze and understand where we had gaps and places that we can do work on.”
The hospital also uses data analyses to understand how specific care processes might be improved, Millburg says. The analyses look at factors such as patients’ comprehension of discharge instructions, their access to and ability to obtain prescribed medication, and the availability of equitable post-acute care in primary or specialty clinics.
Safety Summits with Law Enforcement
Safety Summits are another important aspect of the program. Springfield Memorial works closely with local law enforcement agencies to develop positive relationships and improve methods for addressing violence against healthcare workers, with a particular emphasis on safety in the emergency department. Safety Summits involving law enforcement and hospital staff help increase awareness about the risks healthcare workers face and improve police response.
The Safety Summits improve safety by reinforcing a zero-tolerance stance on violence against workers, patients, and visitors, Millburg says. They also establish that the hospital will collaborate with law enforcement for prosecution when appropriate, and it will enforce visitation expectations at the front entrance.
The meetings also help in developing and implementing planned responses to disruptive or violent individuals. The cooperation between the hospital and law enforcement has resulted in increased presence of off-duty police officers in the emergency department, Millburg notes.
The hospital also advocates for legislation designed to protect healthcare workers and supports a multidisciplinary Workplace Violence Committee, he says.
“A lot of things that came out of the Safety Summits involved working on education of expectations for things like when you’re bringing a patient in that’s maybe been on fentanyl or methamphetamine or something like that, making sure that you go through the proper decontamination process before we’re bringing them into the patient care environment,” Millburg says. “There was a lot of those kinds of learning and education and process refinement opportunities that came out of that, based off of either gaps or maybe just some better ways of doing things that everyone was able to come together and talk about, as opposed to trying to figure out in our own silos.”
Source
- Lance Millburg, Vice President and Chief Quality Officer, Springfield (IL) Memorial Hospital. Email: [email protected].
Greg Freeman has worked with Relias Media and its predecessor companies since 1989, moving from assistant staff writer to executive editor before becoming a freelance writer. He has been the editor of Healthcare Risk Management since 1992 and provides research and content for other Relias Media products. In addition to his work with Relias Media, Greg provides other freelance writing services and is the author of seven narrative nonfiction books on wartime experiences and other historical events.
An Illinois hospital has improved patient safety by implementing a program that encourages reporting of adverse events and near misses. The hospital also encourages staff to report positive experiences that affect the culture of safety and promotes those stories.
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