When a “never event,” a catastrophic failure of care resulting in significant harm or death to a patient occurs, a hospital may focus on capturing and analyzing data on the event and classifying it. But how often does a hospital translate findings into actionable and measurable programs to improve safety?

When a critical incident occurs, the first step is to assess what happened, says Andy Weissberg, senior vice president at Quantros, a vendor of safety software supporting analytics, incident response and clinical quality reporting. Then, a hospital will conduct investigations and analyses then check off the appropriate compliance and peer review boxes on a form.

However, what Quantros and its competitors often see missing is a third process to really learn and make improvements, Weissberg laments. “There seems to be a gap in learning from mistakes; that 360-degree view is really lacking.”

Safety vendors make it easy for clinicians to report a serious event and for risk managers to use analytics to develop uniform workflows and best practices that increase safety, he adds. Progress in improving safety can be measured and shared with senior executives and the board. “If you don’t report in a consistent way, you can’t measure performance in a systematic and measureable way,” says Weissberg. “One department will look at events one way and another will look at events differently.”

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The vendors also sell analytics and performance improvement software to capture data from the time a patient enters a hospital to the time of a serious incident, not only to understand and disseminate findings but act on findings and educate clinicians so they can recognize if a dangerous scenario is developing, Weissberg says.

The ultimate goal of the software is to enable a hospital to know what went down in the workflow from arrival to incident. For instance, a heart attack patient presenting in the emergency department now is in a room at night, in severe pain and asking for medication. The patient receives an opioid, which to some degree depresses respiration. But was the patient’s pre-existing condition of sleep apnea, which already slows breathing patterns, documented in the ED and known to the nurse who gave the opioid?

Consequently, Quantros is now developing decision support software to highlight best practices for avoiding never events and other serious incidents. That will add another level of protection, but Weissberg believes hospital policies also must change to optimize safety. “We need to align compensation for clinicians to reward or penalize them for their standard of care.”

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