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Patient Safety Event Reporting: A Guide to Improving Patient Safety & Outcomes
Navigating the intricacies of patient safety event reporting is crucial for every healthcare facility. Dive into this comprehensive guide to learn how effectively capturing and leveraging event data can promote safety and improve quality of care.
⏰ 27 min read
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Table of Contents
- Introduction & Background
- Section I: The Cornerstone of Effective Safety Event Reporting – Establishing a Just Culture
- Section II: The Mechanics of Safety Event Reporting
- Section III: Analyzing and Leveraging Data from Safety Reports
- Case Studies – Lessons from the Field
- Conclusion – The Road Ahead
Introduction & Background
Patient safety event reporting is not just a regulatory mandate; it is a moral imperative that underpins the trust patients place in healthcare institutions. It encompasses a vast array of safety events, ranging from unsafe conditions or near misses that have yet to cause harm to serious adverse events that can have significant consequences. The rich data harvested from these reports are vital in driving initiatives that elevate the standard of care and safeguard a patient’s well-being. In this guide, we delve deep into the intricacies of patient safety event reporting, laying down a roadmap to foster cultures that value transparency, learning, and collaborative improvement.
Before we explore patient safety event reporting in detail, let’s define some basics first for healthcare workers just beginning their foray into patient safety.
What is a patient safety event?
A patient safety event is any unplanned or unexpected event that results in, or could have resulted in, harm to a patient. Patient safety events can range in severity from minor incidents, such as a patient fall, to more serious events, such as medication errors or wrong-site surgery.
But a well-designed patient safety event reporting system should capture more than just the events that reach the patient. The Agency for Healthcare Research and Quality (AHRQ) has provided standardized definitions and formats used across healthcare settings that are called the Common Formats for Event Reporting (CFER).
CFER enables reporting of:
- Incidents: patient safety events that reached the patient, regardless if there was harm involved
- Near Misses (Close Calls or Good Catches): patient safety events that didn’t reach the patient
- Unsafe Conditions: circumstances that increase the probability of a patient safety event occurring
Why is patient safety event reporting important?
Patient safety event reporting is important for a number of reasons. First, it helps healthcare organizations to identify the root causes of patient safety events. This information can then be used to develop and implement corrective actions to prevent similar events from happening again.
Patient safety event reporting also helps healthcare organizations track trends. This information can be used to identify areas where improvement is needed and to evaluate the effectiveness of corrective actions.
Additionally, event reporting helps to create a culture of safety in healthcare organizations. When healthcare workers feel comfortable reporting patient safety events, they are more likely to do so. This leads to more accurate and complete data, which can be used to improve patient safety more effectively.
Section I: The Cornerstone of Effective Safety Event Reporting – Establishing a Just Culture
Objective:
To create an environment where individuals are encouraged to report safety events without fear of punitive action.
Strategies:
- Develop non-punitive reporting policies.
- Facilitate open dialogues to address concerns and improve systems.
A “just culture” in healthcare is built upon the foundational belief that individuals should not be punished for mistakes attributed to systemic or process errors. In such a culture, reporting safety events becomes a norm rather than an exception, encouraging learning and growth. Let’s evaluate two pivotal strategies that help in establishing a just culture.
1.1.1 Develop Non-Punitive Reporting Policies
In a healthcare setting, where the stakes are notably high, establishing non-punitive reporting policies is crucial for fostering a culture of safety and accountability. This approach ensures staff members can report errors and near misses without fearing retribution.
Key Considerations:
- Confidentiality: Ensure that reports can be submitted with attribution OR anonymously to protect the identity of the reporting individual, fostering a sense of security. (In ADN’s experience, 20% of patient safety events tend to be anonymous.)
- Learning, not Blaming: Steer away from a culture of blame to one that emphasizes learning from incidents to prevent them in the future. Tactics to achieve this can be found in the Increase Event Reporting Toolkit.
- Feedback and Follow-Up: Create mechanisms where the reporter receives feedback and sees tangible actions resulting from their reports, enhancing trust in the system.
- Important Note: Lack of feedback and follow-up is frequently mentioned in Surveys on Patient Safety Culture that ADN conducts for clients as a reason staff don’t report events.
Action Steps:
- Policy Formulation: Craft clear policies that delineate the non-punitive nature of the reporting system.
- Awareness and Training: Organize workshops and training sessions to embed the non-punitive policy into the daily workings of the healthcare institution.
1.1.2 Facilitate Open Dialogues to Address Concerns and Improve Systems
Open dialogues serve as crucial platforms where concerns are expressed and solutions are developed. They demonstrate a commitment to transparency and ongoing improvement.
Key Considerations:
- Safe Spaces: Create environments where individuals can voice concerns without fear, fostering a culture of openness and trust.
- Cross-Functional Teams: Encourage teams from various areas to come together, bringing diverse perspectives to the table and enhancing problem-solving.
- Iterative Improvements: Ensure that dialogues translate into action, with a focus on making iterative improvements based on feedback received.
Action Steps:
- Regular Forums: Establish regular forums for open discussions, where team members can discuss challenges and brainstorm solutions.
- Good Catch Campaigns: Conduct a Good Catch campaign. Near misses carry fewer emotional barriers and less judgment or bias, making them easier for staff to talk about than incidents. A well-run Good Catch Campaign can have a profound impact on culture and deliver measurable improvements in patient safety.
By nurturing a just culture through non-punitive reporting policies and open dialogues, healthcare institutions embark on a path of self-improvement and learning, where every safety event becomes a stepping stone towards a safer, more effective healthcare environment. This collaborative and open approach not only protects the dignity and morale of healthcare professionals but also translates into enhanced patient safety and positive outcomes.
Section II: The Mechanics of Safety Event Reporting
Understanding the mechanics of safety event reporting is foundational to improving patient safety and healthcare quality. In this section, we delve into the essential components and processes that facilitate effective reporting of safety events, near misses, and unsafe conditions. From identifying and categorizing safety events to designing a robust reporting system, we explore the strategies and best practices that foster accurate and insightful data collection. By establishing clear guidelines and promoting open communication, healthcare organizations can create a conducive environment for reporting and learning from safety events, ultimately driving positive change and enhancing patient care.
2.1 Identifying Safety Events
Objective
To delineate clear criteria for identifying safety events, including good catches and unsafe conditions, thereby encompassing a broad spectrum of scenarios from medication errors to surgical complications to an unsafe sharps disposal bin. This concerted approach ensures that all possible safety concerns — not just those that result in incidents that reach the patient — are identified, monitored, and managed appropriately to foster a culture of proactive safety.
Strategies
- Create guidelines and checklists to aid in identifying safety events, good catches/near misses, and unsafe conditions.
- Train healthcare providers in recognizing and reporting safety events promptly.
2.1.1 Create Guidelines and Checklists
In order to facilitate the comprehensive identification of safety events, the creation of detailed guidelines and checklists is pivotal. Event recognition is repeatedly one of the top barriers to reporting. The guidelines/checklist approach not only aids healthcare providers in recognizing a wider array of safety events but also promotes an environment where good catches and the identification of unsafe conditions are encouraged and rewarded.
Key Considerations:
- Inclusivity: The guidelines should be inclusive, encapsulating a wide array of potential safety events.
- Clarity: The checklists should be clear and concise to facilitate quick and efficient reporting.
- Accessibility: Both the guidelines and checklists should be readily accessible to all healthcare providers.
Action Steps:
- Collaborative Development: Engage a diverse group of healthcare providers in the development process to ensure a comprehensive set of guidelines.
- Regular Updates: Ensure the guidelines and checklists are regularly updated to remain relevant and effective.
- Utilize Existing Tools: Leverage existing free tools such as ADN’s toolkit to help hospitals increase event reporting, which includes event recognition posters and many other helpful tools.
2.1.2 Train Healthcare Providers
Training plays a pivotal role in ensuring the effective implementation of any new strategy or guideline. Hence, healthcare providers should be systematically trained to recognize and promptly report safety events, good catches, and unsafe conditions.
Key Considerations:
- Comprehensive Training: Utilize holistic training that includes theoretical knowledge and practical demonstrations.
- Scenario-Based Training: Utilize real-life scenarios for training to better equip healthcare providers in identifying safety events.
- Continuous Education: Establish a continuous education program to keep healthcare providers updated with the latest knowledge and best practices.
Action Steps:
- Development of Training Modules: Create detailed training modules with inputs from experts in the field.
- Feedback and Improvement: Gather feedback post-training and make necessary improvements to the training module based on the feedback received.
- Certificate Program or CE Credit: Introduce an in-house certificate program to encourage healthcare providers to embrace the training. This could even include incentives like extra vacation time, a celebration for new certificate recipients, etc. Additionally, the certificate could include continuing education hours for existing licenses or certifications.
By concentrating on identifying not only safety events but also good catches and unsafe conditions, healthcare organizations can cultivate a culture that is proactive in seeking to enhance safety at every opportunity. Committing to these strategies will contribute to creating safer healthcare environments, with every stakeholder playing an active role in maintaining safety.
The High Stakes of Event Miscategorization
In 2018, American Data Network Patient Safety Organization (ADNPSO) conducted a deep-dive analysis of the event type “Other.” Over a four-year period, this catchall category accounted for over 40% of events reported by ADNPSO members. Among the myriad of striking revelations, the death rate of incidents categorized as Other was 3 times higher than ALL remaining event categories combined. The results of the Other analysis proved so compelling that ADNPSO was selected to present at the National Association for Healthcare Quality (NAHQ) Conference.
Of the 500 random event narratives reviewed for the subcategory “Other Other” (top level category = Other; subcategory level also = Other), ADNPSO recommended that 70% (or 346) were miscategorized and should be recategorized to one of the more specific subcategories or event types.
If your team is using the 80/20 Rule (or Pareto Principle) to prioritize time and resources, events that are miscategorized and hiding in Other may be skewing your data, meaning you may not actually be focusing on the top priorities. Risk Managers should review and appropriately categorize events prior to closing them to produce a more accurate set of priorities. ADNPSO also recommends using miscategorizations as an opportunity to educate frontline staff and curb future errors.
Strikingly, nearly all of the Other events that resulted in death were miscategorized. Of the 500 random Other Other events reviewed, 7 resulted in death; and 6 of the 7 warranted recategorization to more specific subcategories such as Delay in Treatment, Code/Emergency or Medications.
2.2 Designing and Implementing a Robust Reporting System
Objective
To construct a reporting system that is readily accessible to all healthcare providers and structured to capture intricate details pertaining to safety events, ensuring a holistic view of the incidents, near misses, and unsafe conditions. This system aims to promote a culture of transparency and continuous improvement through the meticulous documentation and analysis of safety events.
Strategies
- Prioritize User-Friendly Reporting for Frontline Staff
- Ensure Integration of Feedback Mechanisms
2.2.1 Prioritize User-Friendly Reporting for Frontline Staff
Perhaps the most frequently cited barrier to reporting an event (see table below) is not enough time. Thus, a fundamental step in building a robust reporting system is the implementation of user-friendly report templates (also know as reporting forms) that encourage detailed documentation of incidents, good catches, and unsafe conditions. These forms should not only facilitate easy reporting but also help in capturing vital data that can be analyzed to improve patient safety. Striking a balance between capturing as much data as possible while being user-friendly is a challenge (but one that ADN has achieved given that an independent expert called ADN’s event reporting system the easiest for frontline staff of all the tools in the market). In fact, one ADN client conveyed they had their IT team set the shortcut icon on computers that links to ADN’s event reporting application to be a big red “E” because frontline staff call it “the ‘Easy Button’ because it’s so easy to report an event.”
Key Considerations:
- Clarity: Ensure the form is clear and straightforward to encourage widespread usage.
- Guided Inputs: Incorporate guided inputs, such as skip logic and prepopulated patient data fields, to assist providers in detailing incidents effectively.
- Customizability: Allow the template to be customizable to cater to the diverse needs within the healthcare facility.
Action Steps:
- Scrutinize Available Offerings: Scrutinize the user-friendliness of the reporting form to set the facility up for success. The ease-of-use of the event reporting system directly correlates to the quality and quantity of data you’ll get for data-driven decision making. In your evaluation of the event reporting products on the market, this should not be short-changed. (Consider using a prebuilt gap analysis tool to compare reporting tools.)
- Pilot Testing: Conduct pilot tests to refine to obtain real-world feedback, identify friction points, and establish buy-in.
- Training: Offer training sessions to familiarize healthcare providers with the new reporting template, ensuring ease of use and encouraging its utilization.
2.2.2 Ensure Integration of Feedback Mechanisms
For effective safety event reporting, it’s vital that event reporters, especially frontline staff, receive acknowledgment and feedback on their reports. This type of feedback reaffirms that their efforts in reporting were meaningful and had an impact. Creating a feedback loop centered on acknowledging and valuing the contributions of reporters is key. It not only assures staff that their reports are being reviewed and acted upon but also emphasizes the significance of every report in fostering a safer healthcare environment.
Key Considerations:
- Feedback Channels: Prioritize channels where reporters receive timely feedback. This can include direct acknowledgment messages such as “thank you for reporting” and more detailed feedback when a report leads to further investigations or interventions. While functionalities like commenting and messaging are prevalent in 3rd party event reporting applications like ADN’s, in-house tools may lack these features. Assessing this disparity is crucial if considering an in-house tool.
- Feedback Reinforcement: Apart from immediate acknowledgments, it’s essential to publicize instances where a particular report led to tangible improvements. This not only validates the reporter’s effort but also shows the organization’s commitment to continuous improvement. Daily safety huddles can be effective platforms for public kudos like this.
Action Steps:
- Feedback Workshops: Regular sessions can be held to share broader insights gained from individual reports, and the subsequent improvements implemented. This can serve as a motivational tool for staff to understand the broader impact of their individual reports.
- Recognition Initiatives: A structured reward system can be implemented to recognize and appreciate the staff’s active participation in reporting. For instance, one facility awarded an extra vacation day each quarter to the team member who reported the best near miss during their Good Catch Campaign.
Incorporating feedback mechanisms focused on acknowledging the contributions of reporters ensures that healthcare organizations are building trust and promoting a culture of safety. This approach, emphasizing both immediate acknowledgment and showcasing broader improvements resulting from individual reports, guarantees a proactive, responsive, and engaged reporting environment. The ultimate goal remains the same: enhancing patient safety outcomes by valuing every report and every reporter.
2.3 Overcoming Barriers to Event Reporting
Despite the importance of patient safety event reporting, there are a number of barriers that can prevent healthcare workers from reporting events. Fortunately, healthcare organizations can overcome these barriers if they’re clear-eyed and strategic. The table below identifies the most common barriers to event reporting in ADN’s extensive experience in patient safety as well as tips for how to overcome them.
Section III: Analyzing and Leveraging Data from Safety Reports
Effectively analyzing and using data from safety reports is crucial for enhancing patient safety and outcomes in healthcare. This section explores practical methods and strategies for collecting and interpreting this data to identify areas that need improvement. Transforming these insights into concrete actions is essential for ongoing improvement in safety protocols and practices. In this part of the guide, we’ll focus on how healthcare organizations can make the most of the information gathered to make real and lasting improvements in patient care and safety.
3.1 Data Aggregation and Analysis
Objective
To amass and scrutinize data systematically, extracting crucial insights to spotlight areas necessitating change. A deliberate and thorough analysis is pivotal in transforming raw data from safety reports into actionable strategies that foster heightened patient safety.
Strategies
3.1.1 Employing Sophisticated Data Analytics Tools
In the age data-driven decision making, healthcare data analytics stand as a beacon of insight, helping organizations chart their path forward. Using state-of-the-art data analytics tools, healthcare institutions can delve deep into the safety report data, identifying patterns, discerning trends, and highlighting critical areas of concern.
Key Considerations:
- Tool Selection: Picking analytics tools that are well-suited to the unique demands and complexities of healthcare safety data.
- User-Friendliness: Ensuring the tool interface is intuitive, enabling efficient and effective usage by the designated teams.
- Data Security: Given the sensitive nature of healthcare data, prioritizing tools that ensure the utmost data security.
Action Steps:
- Tool Evaluation: Conduct thorough assessments to select the most apt analytics tools for safety report analysis.
- Note: ADN developed a Patient Safety Event Reporting Gap Analysis Template to help hospitals perform a comprehensive evaluation.
- Training: Organize training sessions to acquaint teams with the tool functionalities, optimizing their analytical capabilities.
3.1.2 Establishing Multidisciplinary Teams
Data, while insightful, often demands a multifaceted perspective for comprehensive understanding. By bringing together experts from various disciplines, healthcare organizations can ensure a more holistic and enriched analysis of safety report data.
Key Considerations:
- Diverse Expertise: Ensure the team comprises members with diverse backgrounds, from clinicians to data scientists.
- Collaborative Approach: Foster a culture of open dialogue and collaboration within the team.
- Continuous Learning: Promote ongoing education and training for team members to keep abreast of the latest analytical methods and healthcare safety trends.
Action Steps:
- Team Formation: Select experts from various fields to form a multidisciplinary team.
- Regular Meetings: Schedule regular meetings to discuss findings, share insights, and brainstorm solutions.
- Feedback Mechanism: Establish a feedback loop within the team to ensure continuous improvement in the analytical process.
Through deliberate aggregation and analysis of safety report data, healthcare organizations are better positioned to identify areas of concern and craft targeted interventions. By leveraging sophisticated analytical tools and fostering multidisciplinary collaboration, the journey from raw data to actionable insights becomes a seamless, efficient process, anchoring patient safety at the core of decision-making.
3.2 Transforming Insights into Action
Objective
To harness the insights gleaned from patient safety analytics, driving forward initiatives specifically tailored to bolster patient safety. This transformation from data to actionable steps is paramount in ensuring that the lessons learned from safety events are constructively applied to the healthcare environment.
Strategies
3.2.1 Developing Actionable Plans Rooted in Data Insights
Translating insights into tangible action is a pivotal step in the patient safety journey. These insights, stemming from rigorous data analysis, provide a roadmap for crafting plans that directly address identified areas of concern in patient safety protocols.
Key Considerations:
- Prioritization: Pinpoint the most pressing concerns identified through data analysis to address first.
- Stakeholder Engagement: Involve relevant stakeholders, from frontline medical staff to hospital administration, in the planning process.
- Resource Allocation: Determine the time, personnel, and/or financial resources required to implement the plan effectively.
Action Steps:
- Brainstorming Sessions: Organize sessions with multidisciplinary teams to develop actionable plans based on identified insights.
- Plan Documentation: Ensure every plan is meticulously documented, outlining steps, responsible parties, timelines, and expected outcomes.
- Roll-out: Launch the plan across the organization, accompanied by adequate training and support for involved personnel.
The Hierarchy of Data Maturity: What Level Are You Really?
Over the years, many organizations to varying degrees of success have embarked on journeys to become “High Reliability Organizations.” But all healthcare organizations, whether they realize it or not, are on a Journey to Data Maturity. Some facilities are more clear-eyed than others about this concept while some may not realize they have stalled on this journey. So ADN developed a tool, the “Hierarchy of Data Maturity”, to help organizations honestly assess their approach to data and benchmark their current actual performance against the goal of reaching the promised land of data maturity.
3.2.2 Creating Feedback Loops
The dynamic nature of healthcare demands that any implemented initiative be continuously monitored and refined. By establishing feedback loops, healthcare organizations can gauge the effectiveness of their initiatives, pivoting and refining based on real-world feedback.
Key Considerations:
- Feedback Collection: Institute methods to actively gather feedback from healthcare providers and patients.
- Data Integration: Merge feedback data with existing safety report data to provide a comprehensive picture.
- Rapid Response: Ensure the capability to swiftly act upon feedback, making necessary adjustments to initiatives.
Action Steps:
- Feedback Channels: Implement varied channels, from surveys to focus groups, to gather feedback on the new safety initiatives.
- Surveys to gather insight might include Patient Safety Culture Pulse Check Surveys, a Culture of Safety Organizational Self-Assessment, an HRO Safety Organizing Scale, or a SOPS® Culture Survey.
- Regular Review: Schedule periodic review meetings to discuss the feedback received and assess the initiative’s impact.
- Iterative Improvement: Based on feedback and review findings, make iterative improvements to the patient safety initiatives, ensuring they remain aligned with the evolving healthcare landscape.
In the ongoing effort to improve patient safety, turning data-driven insights into actionable strategies is fundamental. Through careful planning based on genuine insights and creating environments rich in feedback, healthcare organizations can continually evolve and adapt, keeping patient safety a top priority in their efforts.
Case Studies – Lessons from the Field
In the dynamic landscape of healthcare, a robust patient safety event reporting system stands as a cornerstone for enhancing the quality of care and safeguarding the well-being of patients. The ability to meticulously capture, analyze, and respond to safety events is not just a regulatory requirement but a catalyst for transformative change within healthcare institutions. A well-orchestrated reporting system serves as the eyes and ears of a hospital, unveiling hidden patterns and trends that might otherwise go unnoticed.
The significance of uncovering these hidden patterns is multifaceted. It enables healthcare providers to proactively identify vulnerabilities, mitigate risks, and implement corrective measures, thereby fostering a culture of continuous improvement and patient-centered care. From recognizing trends in falls during shift changes to detecting an increase in needle sticks, the revelations brought forth by a comprehensive reporting system are instrumental in driving proactive interventions and enhancing patient safety.
In the following case studies, we explore real-world scenarios where hospitals have leveraged the power of a strong patient safety event reporting process to uncover hidden patterns and trends. These narratives illustrate the transformative impact of such systems in identifying areas of improvement, implementing effective solutions, and ultimately elevating the standard of care provided to patients. Through these stories, we aim to shed light on the pivotal role of safety event reporting in shaping a safer and more resilient healthcare environment.
Case Study #1: Hospital Uncovers Culprit of Uptick in Staff Needle Sticks
The Director of Risk Management & Compliance of a Louisiana hospital relayed a tangible example of how they used ADN’s Dashboards to unearth a trend that was quickly diagnosed and resolved. “We noticed an uptick in staff needle sticks. Upon investigating, we learned that Materials Management changed supply companies. Using the dashboards, we were able to associate the uptick with the vendor change and ultimately we went back to the previous company.”
Without real-time dashboards like in ADN’s patient safety event reporting application, according to the risk management director, it likely would have taken days or weeks longer for the hospital to identify the root cause, resulting in many more unnecessary needle sticks that can carry serious consequences.
Case Study #2: The Journey from Paper Reports to Digital Insights
For one Hawaii hospital, transitioning away from a paper-based process to ADN’s electronic event reporting application was been transformative to their ability to act swiftly on event data.
The Quality & Performance Improvement leader recalled a recent event in which her team’s newfound speed was unmistakable. “We had an event where a patient fell and was injured while leaving our facility. I got an application alert about it immediately. When I talked to our manager, she showed me the place where the fall happened. The patient came down the steps but didn’t see the curb, even though it was painted yellow, and fell off the curb and landed in the parking lot.”
The team immediately summoned the maintenance crew and tasked them with building a railing that would enforce the use of the wheelchair ramp and prevent stepping off the curb. “So, within literally two days, we had a railing built where that curbing was located. Whereas if we had still been using paper reports, we may not have known the fall happened until longer than it took us to get the fix,” she said.
Six months after transitioning to ADN’s application, the team achieved a 9% decrease in falls from their enhanced ability to analyze and react to fall-related events, near misses, and unsafe conditions.
Case Study #3: Uncovering Hidden Trends with Easier-to-Use Analytics
Another hospital transitioned to ADN’s event reporting application from a different vendor. Perhaps the biggest benefit to the Director of Quality & Risk Management was ADN’s more intuitive and easier-to-use analytics.
She relayed a very tangible improvement resulting from her enhanced ability to uncover patterns and trends that previously lay hidden. “ADN’s event reporting system made it very easy to look at the time of day that events were occurring. When analyzing falls per unit, we were able to identify that in one particular unit there was an increased number occurring at shift change,” she said. “We implemented an action plan to make sure staff were located in high-risk areas during this time. We were able to see an improvement in fall reduction in the unit. If there was a Time-of-Day report in our previous application, it obviously wasn’t easy to find.”
The director said another trend discovered through regular monitoring of the event analytics was an increased number of specimen events. “We identified an increase in the number of specimen events so we started a new collaborative on Specimen Collection and Identification. We had our second meeting today where we are flowcharting the process, and we’re going to initiate a LEAN project focusing on that process,” she said. “This collaborative originated from information collected through ADN’s easy-to-use analytics and staff who feel safe reporting events.”
Conclusion – The Road Ahead
Patient safety event reporting is a foundational element in enhancing healthcare outcomes. By implementing robust reporting systems, fostering open dialogue, and leveraging advanced technology, healthcare organizations can address and mitigate safety concerns effectively.
Real-world case studies highlight the tangible improvements that can be achieved through diligent reporting and analysis. By addressing challenges head-on and transforming insights into actionable strategies, organizations can contribute to a culture of continuous learning and improvement in patient safety.
The vision for the future of safety event reporting is one of evolution and adaptability, with a focus on collaborative learning and transparency. It is incumbent upon healthcare leaders to champion these values, driving forward the mission to improve patient safety and healthcare quality.
By adhering to these principles and strategies, the healthcare community can continue to make strides toward a safer and more accountable environment for all patients.
ADNPSO’s analysis of 116 clinics revealed only 3 events reported PER YEAR per clinic across a 3-year period, underscoring the urgent need for a focus on improving the culture of safety in the outpatient setting.
6 Best Practices for Conducting a Survey on Patient Safety Culture (SOPS)
One of the most vetted measurement tools to quantify your patient safety culture and to identify problem areas is the Survey on Patient Safety Culture™ (SOPS®) developed by the Agency for Healthcare Research and Quality (AHRQ). In this article, you will learn 6 best practices for your next SOPS to both fulfill accreditor and watchdog expectations and, more importantly, to make the process pay off in the form of an improved safety culture for your organization.
⏰ 12 min read
What is SOPS?
The Survey on Patient Safety CultureTM (SOPS®), developed by the Agency for Healthcare Research & Quality, helps hospitals, medical offices, and other healthcare organizations understand how providers and staff perceive aspects of their culture of safety.
Organizations use the SOPS Assessment tool to:
- Raise staff awareness about patient safety.
- Assess the current status of patient safety culture.
- Identify strengths and areas for patient safety culture improvement.
- Examine trends in patient safety culture change over time.
- Evaluate the cultural impact of patient safety initiatives and interventions.
Table of Contents
- Best Practice #1: Give Due-Diligence Consideration to Outsourcing
- Best Practice #2: Pay attention to design details
- Best Practice #3: Monitor the response rate
- Best Practice #4: Promote, promote, promote
- Best Practice #5: Incentivize participation
- Best Practice #6: Compile high-quality analysis for sharing with key stakeholders
All your efforts to create a High Reliability Organization are for naught if patient safety is not embraced at every level, from system to individual. And the only way to quantify your patient safety culture, and to identify problem areas, is by asking.
One of the most vetted measurement tools for this is the Survey on Patient Safety CultureTM (SOPS®) developed by the Agency for Healthcare Research and Quality (AHRQ).
While the AHRQ survey tool has been available since 2004, in recent years it’s gained more attention with the focus from accreditation organizations like The Joint Commission (TJC) and public-scoring watchdogs like Leapfrog.
At the end of 2018, TJC amended its survey process expectations for Patient Safety Culture Assessment.
- An organization will be expected to include its most recent Safety Culture Survey with the required documents listed in the Survey Activity Guide. The surveyors will want to review this prior to the opening conference (or as early in the survey process as possible).
- Surveyors will be tracing safety culture as a part of other survey activities and asking questions to assess safety culture. See Table 2 for sample questions for assessing a safety culture.
- “Hospitals can earn up to 120 points for measuring culture of safety, providing feedback to staff, and creating new plans to prevent errors.”
But AHRQ’s survey is not a one-size-fits-all process. The flexibility — how often to survey, who to survey, how to survey, and what to do with the results — recognizes the enormous variations in size and resources of patient-care organizations. But it also means a large number of decisions have to be made in-house.
Here are 6 best practices for your next SOPS to both fulfill accreditor and watchdog expectations and, more importantly, to make the process pay off in the form of an improved safety culture for your organization:
Best Practice #1: Give Due-Diligence Consideration to the Benefits of Outsourcing Survey Administration and Analysis
Many organizations have continued to feel the strain of the healthcare staffing crisis since the pandemic. So even if you have handled the survey process in-house in the past, your capacity to do so now may have changed. And if you haven’t administered a SOPS in recent years, you might be hesitant to add it to your plate given that AHRQ’s User Guide for Hospital SOPS Version 2.0 outlines a 10-week timeline for planning, creating, conducting, and analyzing the survey.
Some advantages to outsourcing are obvious: The process doesn’t interrupt your normal duties and projects, and you don’t have to reinvent the tools or train someone in-house for a process that only happens every other year.
Some are less obvious: The right outsourcing partner can help you (1) achieve much higher response rates that enrich the results, and (2) receive a more sophisticated and enlightening analytics report faster than you might otherwise. (Our team turns the report around in less than 30 days.)
AHRQ points out several benefits of using an outsourcing partner in the User Guide:
- Working with an outside vendor may help ensure the neutrality and credibility of your results.
- Staff may feel their responses will be more confidential when their surveys are returned to an outside vendor.
- Vendors typically have experienced staff to perform all necessary activities and tasks. A professional and experienced vendor may be able to provide your hospital with better quality results faster than if you were to do the tasks yourself.
When considering these benefits and the fact that outsourcing is very affordable, it’s often worth a brief conversation before you go too far down the road of investing a lot of internal time and resources in administering the SOPS yourself.
Best Practice #2: Pay attention to design details
The pitfalls of a poorly designed online survey are so numerous that AHRQ produced a webinar on best practices as a companion to the SOPS User Guide.
Online surveying has virtually replaced paper surveys for many good reasons: online surveys prevent participants from giving two answers to the same question; they can capture responses if the survey-taker fails to finish all questions; and, most appealing, online survey responses are automatically compiled, resulting in actionable results within days rather than months.
Design elements that really matter include a proper grid layout, alternating row shading to help respondents move smoothly through the answer options, easy buttons for moving back and forth through the questions, and a progress bar to encourage the user to complete the survey. Also crucial is developing a survey that is easy to complete on a mobile device, not just a desktop computer.
Best Practice #3: Monitor the response rate
The ability to monitor responses in real-time is one of the great advantages of online surveying compared with paper surveys, but that advantage is wasted if no one is paying attention until the end of the survey period. A good outsourcing partner will monitor and update you frequently – ADN, for instance, provides response rates at least twice a week at the overall facility and individual department levels – so that targeted promotional efforts can be implemented in a timely manner via huddles or other staff meetings. Your response rate should not be a surprise ending.
Best Practice #4: Promote, promote, promote
Even a well-designed survey will have a low response rate without consistent, multi-channel efforts to promote, encourage, incentivize and remind employees and other desired respondents to start and finish the survey. That means emails, preferably from the CEO; posters in common areas, verbal reminders at routine staff huddles; links on your intranet; etc.
If partnering with ADN, we have a sequence of pre-written email templates with recommended distribution dates/times that have been proven effective.
Best Practice #5: Incentivize participation
Rewards for departments with the highest response rates are more effective than random individual winners. And the reward should reflect the value your organization places on patient safety: an extra day of vacation, a catered meal, or maybe both. Through experience, our team has learned some creative and motivating incentives that we share with clients.
Best Practice #6: Compile high-quality analysis for sharing with key stakeholders
With so much data from a facility-wide survey, the quality of your analytics report can mean the difference between a sea of raw data or a trove of distilled insight. Below are some best practices ADN recommends.
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- Compare to external benchmarks to identify strengths and opportunities. While understanding what’s going on at your facility is vital, make sure you gauge how your performance stacks up to other facilities. When outsourcing with ADN, the comprehensive report you receive includes comparisons to the most recently available AHRQ SOPS databases, as well as an executive overview and detailed breakdowns of the survey data to assist in communicating the results to all internal stakeholders
- Look for differences from baseline and comparators at the department, position title, and work area levels to help further define priorities. Identifying opportunities for improvement is certainly a goal here, but don’t forget to identify top performers as well. Drilling down into the subculture of top-performers can provide a wealth of learning.
- Don’t ignore unstructured data. A lot of intelligence can be buried in unstructured data like narrative answers. Deep-diving “other” responses and coding open-ended replies by themes are great ways to ensure you squeeze every last drop of insight out of your survey data.
- Disseminate survey results at all levels to promote organizational learning and transparency. While the primary audience intended to act on the survey results may be senior leadership, disseminating some findings, strengths, and opportunities throughout other levels of the organization can be very beneficial. It can broaden buy-in, demonstrate everyone has a role to play in the improvement, promote transparency, show that data is being analyzed to be acted on (not just collected), and much more.
- Facilitate multi-disciplinary feedback sessions to inform action planning. The frontline staff have an undeniable role in event detection and reporting but can have an even greater impact when their intimate knowledge of internal systems is leveraged in the PDSA cycle. Frontline can serve as subject matter experts to help identify and define cause-and-effect relationships. When analyzing survey results by work areas or position titles or themes, a cross-discipline team will be able to contribute unique perspectives that uncover or explain trends seen within the survey data. By including representation from all involved disciplines and levels, the team will likely be able to add more context and better match problems with actions and interventions.
- Analyze survey findings in conjunction with other available safety data, such as internal event reports, public safety scores, and more. Some of the SOPS survey questions provide insights into the effectiveness of your existing interventions, such as safety education, event reporting systems, and communication among teams. Evaluating these relationships can inform improvement efforts and resource allocation for addressing aspects that directly affect staff perceptions of safety culture and indirectly benefit other safety-related processes (e.g., enhanced safety orientations and ongoing education, better communication about medications and discharges, etc.).
For more than 25 years, American Data Network (ADN), which is also the parent company to its Patient Safety Organization (ADNPSO), has worked with large data sets from various sources, aggregating and mining data to identify patterns, trends, and priorities within the clinical, financial, quality and patient safety arenas. ADN developed the Quality Assurance Communication (QAC) application, with which hospitals, clinics, rehabs, and other providers record and manage patient safety events. By entering events into ADN’s QAC application and submitting them to ADNPSO, information is federally protected and thereby privileged and confidential. These protections provide a safe harbor to learn from mistakes and improve patient safety.
Fall TIPS: The Fall-Prevention Toolkit that Reduced Falls with Injury by 34%
Fall prevention in healthcare involves managing patients’ underlying risk factors and optimizing their environment to reduce the likelihood of an unplanned descent to the floor. Resources such as Fall Prevention Toolkits have been shown effective in reducing this type of patient safety event.
⏰ 9 min read
What is fall prevention?
Fall prevention in healthcare involves managing patients’ underlying risk factors and optimizing their environment to reduce the likelihood of an unplanned descent to the floor. Resources such as Fall Prevention Toolkits have been shown effective in reducing this type of patient safety event.
Table of Contents
- Choosing a Modality: Paper vs Electronic
- Measuring Success and Evaluating ROI
- Implementing The Toolkit and Establishing Buy-In
- Risks and Interventions
- Responsive to Changing Conditions
A hospital is an unfamiliar setting, and every patient is there because of an illness or condition that requires treatment. It’s a recipe that increases the likelihood of falls, one of the most common and most devastating events in any hospital setting.
While the rate of falls varies among hospitalized adult patients depending on the study, multiple studies indicate that 3-4 falls occur per 1,000 bed days.
A fall, especially by a geriatric patient, can be the start of a downward spiral as described by the team that did early research on the use of a fall prevention toolkit. A single fall can have compounding effects and result in fear of falling, reduced mobility, loss of function and greater risk of falls.”
That early research, published in the Journal of the American Medical Association in 2010, found a significantly reduced rate of falls in the hospital setting when a toolkit was added to usual care protocols. Over the next decade and funded through a grant by the Agency for Healthcare Research & Quality, that research team would go on to further refine their toolkit to help facilities prevent falls. And the toolkit resulting from all that work — Fall Tailoring Interventions for Patient Safety (Fall TIPS) — was recently released for free.
In another JAMA study including more than 37,000 patients published in 2020, the Fall TIPS toolkit was tested at Brigham and Women’s Hospital in Boston and 2 other facilities, finding that falls with injury were reduced by 34% while total falls decreased by 15%. Since then, more than 100 hospitals in the U.S. and internationally have used the toolkit.
Choosing a Modality: Paper vs Electronic
When Fall TIPS was first developed, use of the nurse-led, evidence-based toolkit proved to reduce falls by 25% in acute care settings when implemented as part of electronic record-keeping. The Fall TIPS team then set out to create a “low tech” tool that offered the same benefits in preventing falls, the end result being an 11″x17″ laminated poster on which the personalized plan for each patient is marked.
In the EHR version, the patient’s risk factors and tailored interventions automatically populate the Fall TIPS electronic poster, which a nurse then prints and hangs in the patient’s room. While the integration into a facility’s EHR reduces the potential for error, it also requires the involvement of the IT team to set up. The lower-tech, laminated poster version, on the other hand, can easily be filled out with a dry erase marker and updated daily at the bedside. (A full list of the pros and cons of the paper and electronic methods can be found on the Fall TIPS site under the heading “Paper or Electronic?”)
Whether a high- or low-tech solution is implemented, the goal is to use bedside tools to communicate current and changing patient risk factors, so all stakeholders have access to the information needed to engage in prevention activities.
Measuring Success and Evaluating ROI
The human cost of falls is not the only cost. One-third of falls result in injury, and injurious falls can add a week or more to a hospital stay. The same JAMA study from 2020 found that the additional cost was $19,376 to $32,215. And these costs are not reimbursed by the Centers for Medicare & Medicaid Services because most (more than 90%) of falls are preventable.
When implementing a performance improvement tool like Fall TIPS, it’s always a best practice to start by ensuring you can track and measure success for communication to the team on the frontline as well as senior leadership. The best way to accomplish this is through a Patient Safety Event Reporting Application with real-time dashboards. If your tool has a dedicated Falls Dashboard like ADN’s application (see video below), evaluating falls data pre- and post-implementation of a tool like this is much easier.
Implementing The Toolkit and Establishing Buy-In
At the patient level, Fall TIPS is a three-point plan of action:
- Fall Risk Screening/Assessment
- Tailored/Personalized Prevention Planning
- Consistent Execution of Plan
The toolkit is easy enough to use that compliance was above 80% at the hospitals where it was first tested. So with administrative buy-in and training of patient-care staff, Fall TIPS can become a routine and effective part of patient care. (Subsequent research by the Fall TIPS team showed that a compliance rate of at least 80% is necessary to achieve a clinically significant reduction in falls.)
A poster in the patient’s room is the most visible tool in the toolkit (either the laminated version or the EHR printout). But implementation starts at the top with administrative support. That should include engaging any relevant committees and champions. Some organizations may already have a specific fall-prevention task force, or the appropriate body might be a general quality and safety council. Buy-in needs to come from within the existing organizational structure.
Implementation also includes analyzing existing fall-prevention protocols to see how much overlap there is with the best practices. The toolkit includes a tool to assess gaps in protocols, as well as an implementation checklist and training materials for champions and nurses. (To get started implementing Fall TIPS, click here.)
Risks and Interventions
Whether using the high- or low-tech version of Fall TIPS, the result is a personalized assessment of the patient’s risk of falling and a personalized plan to address their specific risk profile.
Does the patient have a history of falls? Are they taking medications that might contribute to unsteadiness? Do they already use a cane or walker? Are they likely to get out of their bed or chair without summoning help?
Once the patient’s risk factors have been committed to the record, interventions to mitigate those risks can also be committed to the care plan. Is a bedpan appropriate, or should the patient be assisted to the toilet? How many helpers does the particular patient need? Is the risk of getting up unassisted so great that a bed alarm is required?
All of the risk factors and interventions should be discussed with the patient and with family members so that everyone involved understands the plan for preventing falls. In fact, whether the patient and/or family can verbalize the patient’s risk factors and the fall-prevention plan are part of the audit questions that internal champions must answer.
Patient and family feedback has affirmed that knowing the plan improves compliance and can help reduce the fear of future falls, a factor in the downward spiral of fall-prone patients.
Responsive to Changing Conditions
Fall TIPS is not a one-size-fits-all plan for every patient, nor is it static for the individual patient. It can be customized as the patient’s condition changes. The patient’s risk factors and appropriate interventions should be re-evaluated daily. The poster features an assessment date so that every care provider can see how current the evaluation is.
A patient may, for instance, be at greater risk of falling and need different levels of assistance immediately after surgery than before. A change in medications may also change risk factors and the interventions needed. With training and consistent use, Fall TIPS can reduce the number of patient falls and reduce the number of injuries associated with falls that do happen.
To download and start using the Fall TIPS Toolkit, click here.
Learn more about how ADN’s Patient Safety Event Reporting Application can help you uncover trends and patterns about falls in your event data.
Defying Human Nature: 6 Strategies for Increasing Voluntary Event Reporting + Toolkit
Voluntary Patient Safety Event Reporting is a method of collecting details and information about an incident, near miss or unsafe condition in hospitals and other care settings through an electronic or paper-based form submitted by frontline staff. To achieve the highest levels of reliability, organizations must defy human nature by eagerly embracing the evidence of failure. This article will suggest six strategies, and even more specific techniques, for creating a culture that encourages — and even incentivizes — team members at all levels to report incidents, near misses and unsafe conditions.
⏰ 9 min read
What is voluntary patient safety event reporting?
Voluntary Patient Safety Event Reporting is a method of collecting details and information about an incident, near miss or unsafe condition in hospitals and other care settings through an electronic or paper-based form submitted by frontline staff.
As research published in 2020 by the Journal of Patient Safety acknowledged, “A natural, human tendency when errors have occurred is to ignore or minimize the error. It takes a lot of work to build an environment that supports the opposite reaction: open and honest reporting of errors so they can be evaluated to contribute to organizational learning.”
It’s counterintuitive but inescapable: To achieve the highest levels of reliability, High Reliability Organizations must defy human nature by eagerly embracing the evidence of failure. This article will suggest six strategies, and even more specific techniques, for creating a culture that encourages — and even incentivizes — team members at all levels to report incidents, near misses and unsafe conditions.
Encouraging and incentivizing reporting requires first understanding the reasons that team members may fail to do so. As the graphic below illustrates:
- Team members must understand the big picture of preventing future patient safety events by analyzing and sharing past errors. Preoccupation with failure is a mindset that must be fostered at every level. Reporting of safety events and concerns must be recognized as a critical component of patient care.
- Team members must be assured that reporting will not create problems — for themselves, their coworkers or the facility. Fear of immediate personal repercussions is a disincentive to future patient safety. If you want to trust your staff to report safety concerns and events, your staff must trust that they will not regret reporting. Snitches prevent stitches!
What strategies and tactics work?
- Regular education and reinforcement
Awareness of patient safety as a science that must be taught and reinforced has been growing, but your hospital or clinic is an amalgam of patient care providers whose immersion in the mindset and culture of patient safety cannot be assumed. Your facility’s safety culture and processes for reporting issues must be central to the onboarding and orientation process.
As writer Susan Trossman described in a 2017 article in The American Nurse, cultural expectations like engaging in daily safety huddles and working collaboratively must be communicated to new hires and then reinforced in continuing training and routine communication. (Her article also describes an added benefit of intensive orientation, at least with nurses: higher rates of employee retention.)
Safety champions — engaged team members with specialized training — are a tried and true method of reinforcing your desired culture of safety, including normalizing routine reporting of events. Appointing champions per department or location is a great way to ensure the focus on reporting gets regularly communicated on the front lines.
- Evidence of effectiveness
Proving to your staff that their reports of errors and near misses don’t disappear into the ether creates a virtuous feedback loop: Reporting results in improvements, which results in more reporting. An analysis of data from more than 200,000 individuals in almost 1,000 hospitals concluded that prioritizing feedback to reporters is one of the most efficient ways to increase the likelihood that a patient safety event will be voluntarily reported. And this was especially true with the most serious patient safety events. (While you are at it, consider using language such as “safety report” rather than “incident report.”)
- Convenient and natural reporting opportunities
You may be familiar with “nudge theory,” the idea that desired behaviors can be fostered by making them more convenient. (This explains the candy bars in the checkout aisles of grocery stores — and Best Buy.) The desired outcome of voluntary reporting of patient safety events can also be nudged by creating convenient, natural reporting opportunities.
One common and effective strategy is the daily huddle, in which patient safety is the central agenda item for all team members. Periodic observation to make sure daily huddles are being used to encourage event and near-miss reporting is a good management technique. Consider adding the daily question: “How is the next patient going to be harmed?”
Anything that requires a lot of time and effort will always take a backseat to the urgency of patient care, so convenient reporting can also be encouraged with user-friendly reporting technology. This free Patient Safety Event Reporting Gap Analysis template can help you conduct a thorough evaluation of how well or poorly your existing tool or process accomplishes the necessary objectives of an event reporting system.
- Management encouragement
Hearing the gospel of voluntary reporting from evangelists at the top of your organization is key to creating and sustaining a culture of patient safety. These messages from leadership are an opportunity to dispel the fear of retribution from reporting events and instead help promote a just culture at your facility. ADN’s Increase Event Reporting Toolkit can help with templates for emails from senior leaders. Hanging posters reminding frontline staffers of the types of events they should report can keep the responsibility for reporting top of mind. (The toolkit also contains a poster template.)
Every communication channel in your organization is an opportunity for reinforcing the message: staff meetings, intranet, newsletters, etc. But it won’t get done unless someone is specifically tasked with adding safety to the to-do list. Staff meeting agendas and newsletters often feature standing items that carry over from one to the next; voluntary reporting should be one of those standing items.
- Recognition and reward programs
Behavior rewarded is behavior repeated. Recognition of voluntary reporting through “good-catch campaigns” can take the form of certificates or plaques and even that most prized reward: a paid day off for the staff member who reports the best good catch each quarter.
If your state has a patient safety recognition program, be sure your good catches are entered. Whether your staff member is ultimately recognized statewide or not, knowing that their focus on safety has not been forgotten reinforces the original recognition.
- Intensive Reporting Days
It may seem counterintuitive in a culture that encourages reporting of incidents and near misses year-around, but designating intensive reporting days results in more reporting. Research published by the Journal of Patient Safety found that it works at all levels of an organization, especially when reporting can be done conveniently and anonymously.
Clinicians, staff members and patients in 10 family medicine clinics were encouraged to make routine reports during a 10-week study, but they were asked to report every error on five specific days. Their anonymous reports could come through a website, paper forms or a voice-activated phone system. During the 70-day study period, more than a third of the reports came on the five days that were designated for intensive reporting.
ADN’s Increase Event Reporting Toolkit includes an Intensive Reporting Day checklist and support materials to help your organization take advantage of this proven technique for improving voluntary reporting.
Then what?
As you implement new strategies and techniques to improve voluntary event reporting, you can track overall improvement and even compare your facility to other hospitals using ADN’s Patient Safety Event Reporting Rate Calculator. The calculator shows how far above or below average your event reporting rate is as well as suggested reporting rate improvement goals and more recommended strategies, tactics and tools based on your facility’s performance.
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