In November 2018, American Data Network Patient Safety Organization (ADNPSO) is launching a year-long specimen event study to help healthcare professionals, both inside and outside the laboratory, better understand why specimen events happen and how they can collaborate to decrease errors across the testing process.
Last March, American Data Network PSO celebrated the achievements made by the Arkansas hospitals that participated in ADNPSO’s 2017 Good Catch campaign. The pioneering organizations who participated in this study increased Near Miss reporting by 47% over baseline and provided concrete evidence of the learning that happens when Near Miss events are shared and studied. In September, ADNPSO checked in with the 45 Good Catch hospitals to find out how their Near Miss programs are faring six months post-campaign. Forty-two percent of the hospitals responded, and here’s what we learned from them :
First of all, 100% of the hospitals responding to the follow-up survey confirm that their organization continues to hold up Near Miss reporting as a priority. Ongoing reporting and analysis of Near Miss events is viewed as a patient safety improvement strategy that works.
Tip: Hover over or tap graph to view the title and value of the data element.Sixty-three percent of those facilities report a decrease in overall patient safety incidents. And they attribute that improvement to corrections and initiatives established in response to lessons learned through Near Miss reporting.
Emerging – Staff view safety primarily as a requirement of outside regulatory bodies. Compliance with protocols and policies is adequate.
Engaged – Safety performance is an organizational goal with staff striving to reach beyond regulatory requirements to instill practices that improve care.
Empowered – Attitudes of staff, managers and senior leaders are aligned in their approach to patient safety. Event and near miss reporting is ongoing and fueling improvement.
Shifting staff mindset surrounding event reporting was essential and challenging for Good Catch facilities. ADNPSO defined a three-tier scale that hospitals can use to gauge their organizational Culture of Safety. Eighty-four percent of the hospitals describe their current environment as either Engaged or Empowered. In these facilities, patient safety is being embraced at all levels of leadership and staffing.
Together, these first three findings support ADNPSO’s understanding of near miss reporting as an impetus for building trust among teams, strengthening culture, and ultimately serving as a catalyst for decreasing adverse events. The remainder of the survey responses provides insight as to how organizations are sustaining or growing their Near Miss programs as well as what might be holding others back.
The fact that 42% of the facilities have observed a decrease in Near Miss reports since the campaign’s end confirms early speculations: Prioritizing near miss reporting means implementing ongoing efforts to educate staff, provide feedback and reward good catches. Additional findings point to these as strategies that work.
Tip: Hover over or tap graph to view the title and value of the data element.Education, as to the value of Near Miss reporting and proper procedures for reporting, stands out as a driving force for sustainability and growth. While 52% cite the importance of relevant and timely feedback, 68% of hospitals acknowledge encouraging and rewarding staff as a key strategy
Seventy-nine percent of the hospitals confirm continued support from the C-suite and report that progress is being shared in leadership and board meetings. This finding is especially significant because engagement from senior leaders is essential if organization-wide culture change is the overarching goal. Staff respond when they see leadership embracing just culture and leveraging opportunities to turn discovered vulnerabilities into improvements.
Near Misses have remained a routine point of discussion across organizations at multiple engagement levels. In 74% of the hospitals, frontline staff are talking about Near Misses in their meetings, and the same is true at the departmental level. In 58% of the hospitals, senior leaders and board members are also engaging in conversations focused on Near Miss findings. It’s exciting to learn how many hospitals have woven the topic into New Employee Orientation programs and Annual Employee Education plans. Dialogue with physicians and consultations at shift changes offer opportunities for improvement.
Providing education, feedback and recognition needed to sustain Near Miss reporting could be easily done if that were all staff were tasked with, but that’s far from the situation in any hospital. While a quarter of the facilities see no barriers to implementing a Near Miss program, 63% are struggling to balance an overwhelming laundry list of priorities. Cultural issues are also noted. For instance, it’s hard to convince staff that fixing a problem when a Near Miss is discovered, as opposed to reporting it for the sake of shared learning, is not constructive when the team is working to improve care.
Finally, 79% of the hospitals providing post-campaign feedback report improvement in overall culture which is going to position these organizations well for continued success. Effective communication and provision of a safe environment for sharing Near Miss stories are key to engaging staff and ultimately improving care.
According to the Centers for Disease Control and Prevention, sepsis, which is often difficult to diagnose, is a medical emergency in which a quick response is critical. With mortality rates greater th
Leadership responsibility includes assurance that staff recognize all types of events and are supported in their reporting activities. In this ebook, we discuss: What staff needs to be trained on, Examples of patient safety events and near misses, and Leadership To-Do List.
ADNPSO conducted a statewide Patient Safety Good Catch Campaign in Arkansas in 2017. During this campaign, hospitals achieved 95% of the campaign goal and saw a 47% increase in near miss reporting over baseline.
Patient safety and risk data are only actionable when visualized in the right reports. These are the Top 5 Reports every patient safety and risk department should be building to get the best insight into their data.
This Patient Safety Toolkit from ADN includes an Adverse Event Excess Cost & Length of Stay Calculator, a Good Catch Campaign Blueprint, a Heart Failure Checklist and an Anatomy of a Near Miss Guide Infographic.
