The epidemic of patient harm in hospitals needs to be taken seriously if it is to be stopped, and risk management systems are an essential part of the solution, as Brian Stromberg, healthcare sales executive, and David McElroy, director, healthcare practice at Riskonnect, explain to HRMR.
According to the Institute of Medicine in its 1999 report, To Err is Human: Building A Safer Health System, one of the top 10 leading causes of deaths per year are healthcare-related mistakes, and it reported that an estimated 44,000 and as many as 98,000 deaths in the US were from preventable adverse events due to medical errors.
Reporting close calls and good catches
Investigating reported close calls, also called ‘good catches’, is an effective method of preventing the same event from happening in the future with more severe consequences.
Close calls are brief moments when bad things don’t happen. The National Safety Council defines ‘near-misses’ as an event in which no property was damaged and no personal injury was sustained, but given a slight shift in time or position, damage and/or injury could have occurred.
Changing the culture
“To change the culture, you have to have champions as well as good tools and systems,” said Dr Paul Lindeman, chief medical information officer at veEDIS Clinical Systems, in a webinar Health IT and Patient Safety hosted by insurance advisory firm Advisen. Lindeman specializes in connecting clinical, technical, and executive worlds with the single focus of using technology to improve the quality of care for patients.
"WHEN AN EVENT (WHETHER IT IS A CLOSE CALL OR AN ACTUAL INCIDENT) IS REPORTED, STAFF ARE NOTIFIED AND AUTOMATICALLY ASSIGNED A TASK TO COMPLETE PER HOSPITAL POLICY."
“It’s important to encourage the reporting of near-misses and unsafe conditions,” said Brian Stromberg healthcare sales executive at Riskonnect. Stromberg said that organizations need a modern technology solution that makes analyzing that data easy.
“Staff shouldn’t be spending hours generating a report to share with a committee. It should be easy to produce so there is more time to focus on the data to spot trends, do root cause analysis, and implement strategies to prevent these errors from happening,” he said.
The key step is to disseminate report findings back to the staff so they see their time in reporting events is being used to improve patient safety. “If you ask or tell a physician to change his/her behavior, you are going to be met with some resistance,” Lindeman said. “If you have the data to show the physicians, however, they will be moved by that, and they will be much more likely to bring about a change in culture when they have the data to go along with your message.”
Reasons many near-misses aren’t reported
Some may think that if there was no patient injury, close calls do not need to be reported or investigated. Investigation forms may be too time-consuming to complete, or the forms are not easily accessible (eg, they are on hard copy paper). Often, busy caregivers are pressed for time and filling out incident reports doesn’t become a priority.
Punitive action is a valid concern for staff reporting a near-miss. If the organization has a transparent and well-defined safety program in place to identify problems in the system with the end-goal of protecting the patient and not placing blame on the employee, then reporting close calls becomes second nature and will be a collaborative and potentially life-saving effort within your organization.
Simplifying the reporting process
In order for an incident reporting system to be successful and to increase reporting, it must be easy to use and access and be customizable.
Imagine a system that is:
Secure, compliant with all applicable laws and regulations, and doesn’t require a programming degree to operate;
Easily accessible by registered and non-registered users from any computer within your organization, or from any mobile device that has the app installed; and
In which an incident can be easily completed with an interview-style questionnaire customized for your organization.
Riskonnect’s Healthcare Work Platform (Figure 1) enables the complete handling of healthcare risk management, quality of care, patient safety, and employee management. The system brings together many disparate operations that traditionally have been supported by individual applications. The Riskonnect system helps support the reduction of risk, and helps risk managers ensure safety processes are in place to provide greater attention to areas that will increase patient safety and improve patient outcomes.
Riskonnect’s Healthcare Work Platform is customizable, easy to use, and accessible on mobile devices. It is easy to pull up and complete a short form to report an event, meaning it will take very little time away from clinicians to provide patient care. The system’s user-friendliness will result in increased reporting because it’s no longer a hassle.
The Riskonnect system also allows for communication and collaboration. When staff see that they can quickly involve a subject matter expert and get feedback, they can see some of the benefits of reporting events, and this encourages quick intervention and resolution.
Automation in the Riskonnect system reduces the workload. When an event (whether it is a close call or an actual incident) is reported, staff are notified and automatically assigned a task to complete per hospital policy, eliminating this typically manual process.
Reporting events allows you to notify people to put systems in place. An event can be tied to a root cause analysis or to a peer review. Reporting in the Riskonnect system allows risk managers to build a database where everything is integrated onto one platform, making it easier to spot trends as they relate to events, locations, or care providers.
Join a group
Riskonnect has a unique feature called Chatter, which works in a similar way to Facebook. System users can join groups and be updated whenever there’s new information pertaining to that group.
“Sharing in the successes of improving patient safety is an excellent way to encourage and improve the culture of reporting. The staff will be more likely to report knowing that their efforts are benefiting the patients,” said Stromberg.
Patient safety: worse than we thought
In 2013, the Journal of Patient Safety conducted a follow-up study to the Institute of Medicine’s 1999 To Err is Human report, and discovered there was a staggering 400,000 preventable deaths each year in US hospitals, up from the 44,000 to 98,000 estimates first reported 14 years earlier. This makes deaths from preventable medical error the number 3 cause of death in US hospitals, behind cancer and heart disease.
The epidemic of patient harm in hospitals must be taken more seriously if it is to be curtailed. Fully engaging patients and their advocates during hospital care, systematically seeking the patient’s voice in identifying harms, transparent accountability for harm, and intentional correction of root causes of harm is necessary to accomplish this goal. It happens in small steps, from the yellow socks in the inpatient rehab unit, to the staff keeping a keen eye open to spot and report potential unsafe conditions, to the physician quickly responding to an inquiry or event through a handheld mobile device while making rounds. It is all possible with Riskonnect’s Healthcare Work Platform.
Brian Stromberg, David McElroy, Riskonnect, US