Shore up your incident reporting system

According to experts Hospital Peer Review spoke with, the two biggest barriers to a robust reporting system are employees' fear of punitive action and a burdensome policy that requires a lot of work.

"The starting point is for hospitals to develop a system that makes it easy for staff to report adverse events," says Kurt Patton, CEO of Patton Healthcare Consulting in Glendale, AZ, and former executive director of accreditation services at The Joint Commission.

"Sometimes in hospitals people report an adverse event and somebody in a position of authority — the quality department or whomever — starts to ask you so many follow-up questions and asks for so much additional data that you just regret ever having reported it," he adds.

Many hospitals are moving to Web-based reporting systems, but Patton says whatever the system, you must make it simple to encourage compliance. He says oftentimes with Web systems, each page asks a question that must be answered to move on. "If I get a website that asks me one question per screen, I'm never going to want to use it again. And a lot of systems are like that," he says.

"One I've seen hospitals use that's nice is you can call a number and say, 'This is Kurt from 4 South and we have a patient up here that's developed a skin ulcer. It's the patient in 429B, Mr. Smith.' And then quality or risk goes and investigates it. And that's a really easy technique for staff to use."

Jim Conway, senior vice president at the Institute for Healthcare Improvement (IHI) and senior consultant at the Dana-Farber Cancer Institute, concurs. "The first thing I'm saying is we have to simplify the systems. The second is not every one gets an RCA [root-cause analysis]. That there are some issues that get resolved in the ongoing communication among clinicians with their patients. There's some stuff that requires an incident report. There's some stuff that requires a root-cause analysis, and what we really need to understand is what's the most appropriate methodology."

Patton, too, says not every report begs an investigation and that even the smaller incidents can be used for improvement. "That minor incident may not be worth sitting down and spending thousands of dollars of staff time doing an RCA, but somebody in the quality department should certainly be analyzing the frequency of the occurrence," he says. By tracking the smaller incidents and knowing the frequency, you can uncover areas that need improvement.

Conway says many facilities spend a lot of time on capturing the information but not using it to facilitate improvement, and that, he adds, does not motivate staff to report. What motivates staff is not being punished for reporting and seeing that something is done about what is reported.

"I go to some organizations where staff report stuff and nothing happens. And it's not that anybody is bad, it's not that leaders are bad, but there's so much stuff coming in, there's not a good process to do that, there's not appropriate levels of delegation. So one of the ways to really stimulate reporting is, part of the culture, when you report something there's a mechanism to do something to drive change and improvement. If you do that, then people will say, 'Wow that worked. I'll do another one of those.'"

Conway says, too, hospitals should move away from blaming an individual when an incident occurs. "We have done an awfully good job in health care of expecting people who are great people who suffer from being human to be perfect 100% of the time. And they can't be. So when we begin to understand when is it about individual responsibility, when is it about shared responsibility, and when is it about system responsibility — when we begin to understand that and practice that — then people will be far more willing to come forward and enter the system.

"That's all part of moving from this compliance focus [and asking] 'Who caused the pressure ulcer?' to 'Where do we have a problem with pressure ulcers and then how do we sit down at a table to figure out how we make this go away?'"

Patton says there are other, "passive" ways to uncover incidents. "As people screen medical records, there are clues that come through, and those clues can be triggers to say, 'Maybe there's an adverse event here of some sort.' You see that a lot of times with medication errors. When an order comes through and it says d/c [discontinue] all meds, Benadryl stat, that doesn't take a whole lot of brain power to say, 'Oh wait a minute, maybe this patient is having some kind of allergic reaction to their meds.' And that doesn't necessarily require an employee to fill out an incident report, but that by itself should trigger people to investigate that case." He says seeing "d/c all meds" in a chart would be a "dead clue" that a patient is having an allergic reaction. That issue, being a medication-related one, you may want to delegate to the pharmacy to investigate.

He suggests looking for other "passive triggers." "If you look from a medical record/coding perspective, there may be things that they can identify at the hospital that aren't being reported but they ought to be analyzing. The patient that comes in without a skin ulcer, when that gets coded a few days later and the patient now has a skin ulcer, that should somehow be culled from the hospital's computer system and reported to risk management or quality for people to review that," he says.

Conway says, "The OIG is very, very concerned about the amount of preventable harm that happens in the United States that nobody appears to be doing anything about. So they have put a tremendous focus on governance and governance responsibility for quality and safety. They've been a major supporter of IHI's work in getting the board on board."

Both Conway and Patton say evaluating your hospital's culture is integral in understanding barriers to reporting. The Agency for Healthcare Research and Quality's tool on evaluating staff perception of culture is useful here, too. Conway suggests also looking at IHI's self-assessment tool to see if you have systems in place for proper crisis/disclosure management (visit and select "IHI Disclosure Culture Assessment Tool").

Disclosure, he says, is part of a process. First, when a practitioner forgets, for instance, to order a lab test or to give a patient medication, do you tell the patient then? And then how do you support people after a disclosure and how do you resolve a crisis after it's reported?

"And the last piece is ongoing learning and improvement. What we're finding is organizations are remembering to do the disclosure, and they're really working hard to do that right, but then the case gets referred to the malpractice carrier and nobody follows up with the family," he says.

"Do you have a policy in place on patient communications? Do you have a documented flow of how communications flow when an event happens?" he says. Because there should be a policy in place to follow immediately after an incident occurs.