Patient Safety Reporting: High Reliability Drives Progress Toward Zero Harm

Added on Aug 4, 2020

By Tejal Gandhi, MD, MPH, CPPS, Chief Safety and Transformation Officer and Mike Personett, Senior Vice President, Reliability & Safety

Patient safety is recognized as the foundation of high-quality care, and the goal of zero harm has been widely adopted across health care systems. While awareness and goal setting are essential, real inroads in advancing patient safety require optimized reporting systems that more reliably drive actions that reduce harm.

Patient safety reporting systems identify, collect, report, and analyze safety events and near misses. To be optimally effective, these programs must be part of a comprehensive learning system built on the principles of high reliability in which safety events are seen as opportunities for improvement. Such systems use data to inform action, include reliable feedback loops to enable learning and improvement, and are capable of measuring their own impact.

As in other complex, high-stakes industries, safety reporting in health care has been used as a way to measure serious safety event rates[1] and as a measure of culture change, where increased reporting can indicate a culture that prioritizes transparency and improvement over punishment. However, issues exist with reporting of patient safety events. In particular, the event reporting systems employed by many health care organizations generate thousands of reports each year that require review, triage, and action, and yet capture a small proportion of relevant events.[2]

In one study, researchers concluded that most of the more than 1,600 U.S. hospitals evaluated did not maintain effective event reporting systems.[3] In addition to lack of physician reporting, most hospitals surveyed in the study did not have robust processes for analyzing and acting on aggregated event reports. Failure to receive feedback after reporting an event is also a commonly cited barrier to event reporting by both physicians and allied health professionals.[4] Without an effective learning system, patient safety reporting requires too much review time by team leaders, is expensive, can generate an overwhelming volume of data, and likely will not meet the goal of eliminating harm.

A 2016 article contrasted event reporting in health care and other high-risk industries, such as aviation.[5] The author proposed that event reporting systems in health care have placed too much emphasis on collecting reports instead of learning from the events that have been reported. In addition, front-line clinicians and clinical managers often fail to receive critical information about adverse events and trends—learnings that could lead to changes to reduce future harm events.[6] 

Breaking down these barriers requires moving away from a focus on safety reporting systems as mechanisms for simply collecting data and toward their integration as key components of a high reliability operating system that optimizes learning and improvement.

Below, we describe common user challenges with current safety reporting systems and processes, as well as solutions supported by the Press Ganey High Reliability Platform™ (HRP™).

 

Client Challenges

 

Safety Reporting System Solutions

Safety report submission takes too much time.

  • Simplify the level of detail you ask for in the first report.
  • Match the data collection with the review process.
  • Improve integration with the EHR to launch event forms and ease and improve patient data capture.

I am overwhelmed by the number of reports/we don’t have enough resources to manage the reports.

  • Define a risk analysis method that helps prioritize reports that need immediate analysis.
  • Trust the methodology to push some events to a track/trend category and periodically audit the category to adjust your methodology accordingly. This process should improve relevance detection over time.

Reported events go into a black hole.

  • Provide meaningful feedback for specific events and build overall team awareness of safety concerns through real-time activity tracking and avoidance of generic user accounts.
  • Engage entire staff in the improvement cycle to foster an appreciation for the enterprise investment in eliminating harm.

We have lots of reports, but we are not seeing improvements and/or the same issues happen over and over again.

 

I don’t know how to analyze all this data to get real insights.

 

We look at cases one by one and have trouble finding trends.

  • Design a triage process that can detect common themes and quickly classify them for aggregate analysis.
  • Conduct periodic common cause analysis to help teams identify patterns.
  • Use tools to evaluate the strength of action items to confirm that analyses are informing stronger actions.
  • Align safety with your process improvement team efforts to ensure the appropriate improvement occurs.

It is unclear who is responsible/accountable for what needs to be fixed locally vs. at a higher or broader level.

  • Establish processes to ensure that multidisciplinary root cause analyses inform meaningful change.
  • Manage action plans using a defined daily management process that does the following:
    • Delineates when a plan requires review by a central committee
    • Identifies items that can be implemented within a team
    • Determines what can be done locally vs. what requires escalation
  • Evolve your process from spreadsheets and email to a central action planning system to help all stakeholders understand the pace and magnitude of change in your organization.
  • Manage recommendations and prioritize efforts that set teams up for success and ensure positive momentum over time.

 

Integrating safety reporting processes such as these into a comprehensive learning system grounded in the principles of high reliability allows organizations to build the kind of high-value safety program needed to drive toward zero harm.

 



[1] “SEC & SSER Patient Safety Measurement System for Healthcare,” 2016 white paper, Press Ganey Associates, Inc., https://www.pressganey.com/resources/white-papers/sec-sser-patient-safety-measurement-system-for-healthcare.

[2] Agency for Healthcare Research and Quality, https://www.psnet.ahrq.gov/perspective/conversation-withkaveh-g-shojania-md. Accessed July 23, 2019. [2015b]

[3] Farley, D.O., A. Haviland, S. Champagne, et al., “Adverse-event-reporting practices by US hospitals: results of a national survey,” Qual Saf Health Care 17 (2008): 416–423.

[4] Evans, S.M., J.G. Berry, B.J. Smith, et al., “Attitudes and barriers to incident reporting: a collaborative hospital study,” Qual Saf Health Care 15 (2006): 39–43.

[5] Macrae, C., “The problem with incident reporting,” BMJ Qual Saf 25 (2016): 71–75.

[6] Sexton, J.B., K.C. Adair, M.W. Leonard, et al., “Providing feedback following Leadership WalkRounds is associated with better patient safety culture, higher employee engagement and lower burnout,” BMJ Qual Saf 27 (2018): 261–270.