Healthcare News
Everything You Need To Know
We know you’re busy. So we research, curate and report healthcare news you need to know.
We know you’re busy. So we research, curate and report healthcare news you need to know.
Event reporting is essential to identifying, understanding, and addressing underlying factors and circumstances that contribute to medical errors. The insight unearthed from reported incidents, near misses and unsafe conditions shed light on fractured systems and processes that might otherwise lay hidden. To help facilities in their pursuit of zero harm, ADN developed an extensive toolkit to help your facility increase event reporting to help you gain maximum visibility into opportunities to improve care outcomes.
The American College of Cardiology’s National Cardiovascular Data Registry (NCDR) is a suite of data registries related to cardiovascular care that helps hospitals, health systems, and practices measure and improve care outcomes. With a decade of experience in specialized registry abstraction and management both as hospital staff and as an Account Lead for ADN’s Core Measures & Registry Data Abstraction Outsourcing Service, ADN’s top NCDR expert, Tammy Holton, shared 5 best practices for effectively managing your facility’s NCDR program.
Preoccupation with failure in healthcare refers to the need for continuous attention to anomalies that could be symptoms of larger problems in a system. High Reliability Organizations (HROs) that demonstrate a preoccupation with failure strive to detect small, emerging failures because these may be clues to additional failures elsewhere in the system. At its root, preoccupation with failure is a mindset that anticipates and specifies significant mistakes that an organization doesn’t want to make.
⏰ 12 min read
Preoccupation with failure in healthcare refers to the need for continuous attention to anomalies that could be symptoms of larger problems in a system. High Reliability Organizations (HROs) that demonstrate a preoccupation with failure strive to detect small, emerging failures because these may be clues to additional failures elsewhere in the system. At its root, preoccupation with failure is a mindset that anticipates and specifies significant mistakes that an organization doesn’t want to make.
Erin Madden, a patient care assistant at Phoenixville Hospital near Philadelphia, made sure that her patient’s bed wheels were locked before transferring her patient into bed. The bed moved anyway. And while her patient didn’t fall and no harm was done, the incident nagged on Madden’s mind.
At her unit’s daily safety huddle, she reported her concern about unreliable wheel locks. Her report led to the discovery that more than half of the beds on the unit were unstable even when the wheel locks were engaged. That discovery led to assessment and repair of wheel locks hospitalwide — and to Erin Madden being recognized in the Pennsylvania Patient Safety Authority’s annual “I Am Patient Safety” contest in 2017.
This anecdote, in which a relatively low-level care provider recognized the systemic implications of a “near miss” with one patient, illustrates one of the five traits that High Reliability Organizations (HROs) employ in order to operate for extended periods without serious accidents or catastrophic failures: preoccupation with failure.
Preoccupation with failure is not a checklist, although checklists can certainly be part of patient safety. “Preoccupation with failure is a mindset, a way to mindfully organize work, applied by all staff every day on the job,” researchers at Johns Hopkins Armstrong Institute for Patient Safety & Quality wrote in 2017.
The mindset that is preoccupied with failure “look[s] for errors rather than assuming what is in front of them is correct,” the Armstrong researchers wrote, referring specifically to frontline clinicians. “For example, when nurses conduct a high-risk intravenous medication double check, the second nurse should assume the first nurse made a mistake, hunt for it, and correct it, rather than assume the intravenous pump is working or programmed properly and the medication is right.”
This thought process — something here might harm my patient, and I’m going to find it and fix it — is a preoccupation with failure. But it does not come naturally; it is a habit that must be taught and reinforced. The Armstrong researchers suggested adding preoccupation with failure to classroom training for health care providers — “For example, in a simulation laboratory students or physicians could identify errors with a mediation pump or a ventilator set up.” — and reinforcing the mindset during clinical rotations.
In the health care setting, unit-level managers can continually reinforce the preoccupation with failure during daily huddles or briefings. “Managers can also ask frontline staff that thought-provoking question, how will the next patient be harmed, and use their responses to proactively identify and mitigate those risks,” the Armstrong researchers suggested.
Spotting and fixing safety risks before they do harm is not enough. Reporting these near misses or good catches should be seen by frontline caregivers “as equally important in the scheme of event reporting.” Why? Because more near misses reported results in fewer serious events in which patients are actually harmed — the goal of every HRO.
Like preoccupation with failure, reporting good catches must be taught and incentivized. Multiple studies have confirmed that providers report more good catches when they are encouraged to. For instance, the American Academy of Family Physicians National Research Network invited clinicians and staff in 10 family medicine clinics to report errors during a 10-week study. Five days during the study were designated for reporting every error they observed. Ultimately, 37% of the reports were made during the five intensive reporting days.
The same is true internally. The Pennsylvania Patient Safety Authority tracked reporting in four hospitals that had good catch reporting systems in place. Between 2005 and 2016, the number of good catches reported by the hospitals increased by more than 60% (from 33,777 in 2006 to 54,472 in 2016) while the number of serious events decreased by 14%.
As the example of the defective wheel lock illustrates, the preoccupied mindset and reporting must be followed up with managerial action. That often includes a formalized data collection process — like American Data Network’s Patient Safety Event Reporting Application — but it can also include the virtuous cycle of recognition that incentivizes more alertness and more reporting that reduces harmful events.
Some health care settings have used internal newsletters to recognize good catches, especially those that have led to systemic improvements. Greater Baltimore Medical Center, for instance, used its MD Today publication for physicians to describe the near miss that resulted in epinephrine and ephedrine no longer being stored next to each other in medication storage areas.
One facility that participated in a 47-hospital Good Catch Campaign led by American Data Network Patient Safety Organization (ADNPSO) offered as part of its recognition program an extra vacation day to quarterly award winners.
While there’s no single roadmap to becoming preoccupied with failure, a successful focus on failure often starts with obsessive data scrutiny.
The recommended tactics included below all fall into 3 main categories:
To become more preoccupied with failure and begin answering these questions, utilize the 7 free tools and resources available below.
What does my existing data tell me?
What data am I lacking and how do I get it?
What effect does the underlying culture of patient safety and reporting have on the quality and quantity of my data?
For more examples and anecdotes of notable good catches, see the Pennsylvania Patient Safety Authority’s annual “I Am Patient Safety” awards, which include brief descriptions of the award winners:
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/2017IAPS.aspx
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2018_Winners.aspx
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2019_Winners.aspx
http://patientsafety.pa.gov/NewsAndInformation/Brochures/Pages/IAPS_2020_Winners.aspx
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.
The Safety Organizing Scale (SOS) was designed to analyze self-reporting team behaviors that contribute to an organization’s culture of safety.
ADN’s Patient Safety Event Reporting Rate Calculator can help your team assess how your number of events reported per number of patient days compares to other hospitals’ reporting rates.
This free 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.
10809 Executive Center Drive
Searcy Building, Suite 300
Little Rock, AR 72211
(501) 225-5533
(501) 222-1083 Fax
Falls Prevention Initiatives That Make a Difference
Falls in healthcare settings are a significant public health concern. They have consequences ranging from hip fractures to a heightened fear of falling. Not only do they increase bed time, but they can drastically reduce a patient’s quality of life.