How patient safety incident reporting improves care
A holistic, data-driven approach to safety improvements – focused on incident reporting, automated event detection and care audits – is imperative.
The erosion of patient safety gains during the COVID-19 pandemic continues to sound healthcare alarms.
Leaders from the Centers for Medicare & Medicaid Services and the Centers for Disease Control and Prevention recently noted: “We have observed substantial deterioration on multiple patient safety metrics since the beginning of the pandemic, despite decades of attention to complications of care.”
Safety audits and error reporting have also fallen by the wayside due, in large part, to the exhaustion of frontline staff and personnel shortages.
To improve safety, healthcare leaders must find new and simpler ways to support safety practices. They must renew their focus on creating a safety culture in which staff continually scan and monitor their environment to identify and correct even minor deviations that could lead to unsafe conditions.
A holistic, data-driven approach to safety improvements – focused on incident reporting, automated event detection and care audits – is imperative to future-proof healthcare organizations.
Simplify incident reporting
The Institute for Healthcare Improvement notes that error reporting should be one component of an organization’s larger effort to detect and prevent harm.
“Public health researchers have established that only 10 to 20 percent of errors are ever reported and, of those, some 90 to 95 percent cause no harm to patients,” the institute notes. “For example, a wrong medication prepared and delivered to the patient may or may not cause harm.”
Indeed, incident reporting is one piece of a broader safety strategy that identifies errors and helps pinpoint system flaws and failures that create opportunity for harm to occur.
The institute further elaborates on the value of focusing on harm with this example: “When a patient admitted for routine surgery gets a staph infection while an inpatient, that hospital-induced illness is certainly harmful. The harm is caused not by individual error but by an institution’s inadequate germ-protection system”.
Other essential steps
Incident reporting is one of three important ways that actual or potential harm is identified; the other two methods are:
Automated surveillance. Data values that exceed expected ranges are automatically detected and elevated to the appropriate patient safety team member. Examples include:
- Drugs ordered, such as Benadryl, which is a common antidote for an allergic reaction;
- An abrupt medication stop;
- Lab results; and
- Patient symptoms, such as a stage 1 pressure ulcer or unexplained lethargy
Care audits. Systematic reviews of any of the following to fill data gaps in the electronic health record and create a holistic view of harm, risk and care deviation:
- Care processes (e.g., central line insertion, wound care);
- Outcomes (e.g., post-operative complications);
- Structure (e.g., resource and equipment availability); and
- Significant events (e.g., medication errors, patient complaints).
The ongoing monitoring of patient safety data, using the latest software, supports a comprehensive analysis of all-cause harm. Organizations should conduct deeper data analysis and improve their data interpretation accuracy to set priorities for improvement work and intervene to prevent or mitigate harm.
An enterprise safety program
Incident reports are a valuable component of an enterprise safety program because they create visibility to conditions that lead to errors and may cause harm. Mistakes in healthcare are rarely due to a single point of failure; they almost always result from a combination of human error, unsafe procedures and equipment issues.
The tendency to blame individuals involved in safety events has led to a crisis of underreporting, where staff are unlikely to document mistakes or near misses for fear that they will be punished. This lack of visibility prevents organizations from putting systems in place that would help guard against similar errors in the future.
Voluntary incident reporting enables safety leaders to identify and investigate conditions that create risk for error. An analysis of the root cause of each incident or event supports thorough consideration of all factors that may have led to the incident, including:
- Sequence of events and timeline;
- Nature, magnitude, location and timing of the incident;
- Changes in people, equipment or information; and
- Controls in place that may have failed.
Incident reports help organizations identify individual and system-level factors that contribute to medical error, foster transparency and support a continuous improvement culture.
Automation can assist with this process; event investigators could benefit from the use of technology to document the chain of events leading up to each event, as well as after the event. Recently developed tools seek to offer an updated user experience and the ability to improve the effectiveness and efficiency of incident reporting to complement a broader safety strategy.
Automation can fit into an effective three-pronged approach that includes trigger-based data surveillance, incident reporting and care audits.
Health Catalyst Editors is a team of senior editors and writers at Health Catalyst offering experience and broad knowledge of the industry.
This blog, written by Health Catalyst, first appeared here. Health Catalyst offers a new module in its Patient Safety Monitor application called Voluntary Event Reporting, which enables the use of analytics to support safety initiatives.