Improved reporting first step in reducing injuries
By Patrice Spath, RHIT
Brown-Spath & Associates
Forest Grove, OR
A high priority has been placed on improving incident reporting as the first step in reducing unintended patient injuries. The incident reporting system in many health care organizations is evolving into one that focuses on near misses, provides incentives for voluntary reporting, ensures confidentiality (not necessarily anonymity), and emphasizes data collection, analysis, and improvement.
The process of incident monitoring has, in the past, been criticized because of the limited ability it has to identify the systemic problems underlying adverse event occurrence. Some important categories of incidents are unlikely to be identified using this system (e.g., incidents involving errors of omission rather than commission).
If incident monitoring and management is to be effective, it must be facilitated and interdisciplinary. Effective incident monitoring also is dependent on a commitment to act upon the information that arises from the process for improvements in the systems of care. Such action is the responsibility of the patient safety or quality oversight committee of the facility.
By implementing facilitated incident evaluations to enhance voluntary reporting, a greater range of incidents can be identified. In addition, the interaction between caregivers during the discussion of incidents can lead to a better understanding of the underlying system issues that contribute to incidents. The objective of facilitated incident monitoring is to strengthen the current reporting system, assist in the identification of a greater number of incidents that occur in during the provision of patient care, and provide a forum for acting on the knowledge derived from incident investigations to improve the safety of patient care.
Facilitated incident evaluation is done at the department or unit level. During regularly scheduled staff meetings, time is allocated to a discussion of the incidents occurring in the clinical area in the previous time period, e.g., the past week or past month. Ideally, the quality manager or patient safety officer facilitates these discussions. The participants are provided with a list of incidents that have been voluntary reported using the current reporting process. Next, people are asked to add to the list any other incidents. By asking the group some pointed questions, unreported incidents could be identified. The questions will be slightly different for each department/unit and the incidents being considered. For example, staff members in a surgical nursing unit might be asked the following question: In the past week, have there been any:
- Medication errors?
- Intravenous line infections?
- Unanticipated admissions to ICU?
- Patient falls?
- Wound infections?
- Noncompliance with practice guidelines?
- Inappropriate admissions/treatments?
- Unreported test results?
- Test reports not acted upon in a timely fashion?
- Delayed, premature, or inadequate discharges/ transfers?
- Patient or family complaints?
- Any pressure ulcers?
- Any gaps in care?
Staff in other departments would be asked a different set of questions more relevant to their practices and expected incidents.
Pertinent details of the incidents identified through this questioning process are added to the list. If insufficient information is available regarding an incident, a person should be assigned to follow up and re-present the issue at the following meeting. Once the list has been updated, a member of the group or the facilitator leads a discussion about the incidents. Patient and provider information should, when possible, be de-identified. Incident discussion should be robust, but the approach always should be educational rather than faultfinding. The focus should be on identifying the system issues in the care delivered.
To assist the discussions, the following questions can be asked of the group:
- What did we do or what did we forget to do that contributed to these incidents? (It should be recognized that errors of omission are far more common than errors of commission.)
- What needs to be done at this level to prevent this incident from occurring again?
- Who is responsible for follow-up action?
- Who else needs to know about this? For example, does it need to be reported to the facility’s quality committee — for action or information?
If a deficiency in the system is identified, the group may recommend a new or revised practice, improved lines of communication, or other department or unit-level actions. If there are concerns about an event involving more than one department/unit, then an interdepartmental meeting to discuss the incident in greater details should be arranged. Issues will not be resolved merely by sending finger-pointing memos to other departments. If a broader system/facility issue is identified, it should be reported to the facility’s quality or patient safety committee.
Facilitated incident monitoring should be a continuous, ongoing fundamental activity for every clinician and department. The statistical reports of events identified through voluntary incident reporting systems can be very useful; however, facilitated discussions of incidents can yield many additional benefits. Caregivers begin to feel more personal ownership of incident reduction activities and have a firsthand opportunity to experience the nonpunitive value of analyzing incidents.
Another type of facilitated incident evaluation is morbidity and mortality (M&M) review. This meeting, held on a regular basis to review deaths and adverse outcomes in patients of a specified clinical group or specialty, can be a valuable multidisciplinary mechanism for critically analyzing the circumstances that surrounded the outcomes of care. These outcomes should include all deaths, serious morbidity, and clinically difficult cases. M&M review should not be used only to review the exotic cases that may be of interest to a larger group of clinicians. The goal of M&M review is to make recommendations for improving the processes of care, initiate actions on these recommendations, and oversee the progress of these actions. Ideally, M&M review meetings are multidisciplinary and include all clinicians, technicians, and managers who are involved in the care of that clinical group of patients. Meetings should be held regularly; ideally once a month.
To be effective, the meeting discussions should focus on identifying the issues related to the processes or systems of care that led to the death or incident and not on the individuals who provided the care. To ensure the discussions are used for educative purposes and not for apportioning blame to individuals, a trained facilitator may be needed.
A brief report should be compiled after each M&M meeting that identifies the actions that must be taken as a result of the discussions and review. If there are no recommendations for action, that should be so recorded. If action cannot be taken at the clinical level, a report should be sent to the facility quality council identifying the issues that need to be addressed at that level. All action items should be placed on the agenda for the next meeting.
Poor teamwork and communication contribute to many untoward incidents. Direct interactions between the members of the health care team are beneficial in ensuring that lessons are learned from each near miss and adverse event.
Effectively facilitated multidisciplinary incident evaluations can provide a forum for these interactions.