Using Event Reports to Design Safer Systems: Part II

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From the course by Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

56 ratings

Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

56 ratings

Course 2 of 7 in the Specialization Patient Safety

Safety culture is a facet of organizational culture that captures attitudes, beliefs, perceptions, and values about safety. A culture of safety is essential in high reliability organizations and is a critical mechanism for the delivery of safe and high-quality care. It requires a strong commitment from leadership and staff. In this course, a safe culture is promoted through the use of identifying and reporting patient safety hazards, accountability and transparency, involvement with patients and families, and effective teamwork.

From the lesson

Event Reporting and Second Victims

Patient safety event reports are a critical data source for identifying and mitigating harm in high reliability organizations; yet, many healthcare organizations do not take full advantage of this data. At the conclusion of this module, learners will understand how event reports should be used to design safer care systems and how organizations can provide support to staff involved in medical errors.

How to Submit an Event Report9:25

Journey of an Event Report3:04

Event Reporting and High Reliability3:28

Using Event Reports to Improve Safety and Culture3:09

Reporting Culture4:04

Using Event Reports to Design Safer Systems: Part I2:34

Using Event Reports to Design Safer Systems: Part II5:01

A Sample Event Review Meeting12:34

Introduction to the Learning from Defects Tool12:50

Disclosure of Medical Errors2:49

Second Victims7:30

Peer Support: Making a Difference for Second Victims8:48

Meet the Instructors

Eileen Kasda

[MUSIC]

In this video,

we'll continue to discuss how we can use event reports to design safer systems.

This is a quote from James Reason's, Human Error book.

He said that rather than being the main instigators of an accident,

operators tend to be the inheritors of system defects.

Their part is that of adding the final garnish to a lethal brew that has been

long in the cooking.

When we think about event reporting data,

one of our challenges is to identify system issues that can then be mitigated.

As we realize that using quantitative data is not always a valuable tool,

here are some ways we can use event reporting data.

We can use it to identify system defects, to monitor new processes, and

identify good catches, to monitor policy compliance and effectiveness.

We can conduct deep dives and we can monitor trends after change, for

example, the opening of a new clinical building.

Often in healthcare, we're so

overwhelmed by the amount of data that we have from event reporting systems that we

don't even know where to begin prioritizing our investigation.

We can learn from high reliability organizations.

HROs use their event reporting data to challenge assumptions of current problems.

Often when investigating events, someone will say, wow, that surprises me.

Feelings of surprise are a solid cue that what we thought was going to happen

didn't.

These are a great opportunity to dive deeper and analyze them.

Another way high reliability organizations prioritize events is by focusing on what

individuals can count on to not fail, while doing what is expected of them.

This allows us to focus on maintaining reliable performance.

HROs have three questions that they consider when reviewing event reports.

What do people count on?

What do people expect from the things they count on?

And in what ways can the things people count on fail?

By considering these things when reviewing data,

we're often able to identify system issues that could be mitigated.

Another way HRO's prioritized events is by using

risk priority matrices like the one here.

This is an example from the joint commission, it's the SAFER matrix.

This looks at the potential for harm versus how widespread a risk is.

Organizations can plot potential hazards on this risk, and

then use mitigation strategies to try to decrease them.

For example, an organization might identify hazards and

errors related to ordering medications or ordering labs.

Mitigation strategies can be put in place.

And through those mitigation strategies,

you can actually change where these hazards show on the risk matrix.

When designing SAFER systems and putting mitigation strategies in place,

healthcare should consider if they're implementing weak actions,

moderate actions or strong actions.

Weak actions tend to be person based and

involve things like reeducating staff or creating a policy.

Stronger system level designs, though, create forcing functions so

that the error can't happen again.

The stronger the action,

though, the more effort that is involved to implement that action.

Lastly, it's important to remember to debunk the black hole myth.

Often we hear from front line staff that events go into a black hole.

And in order to

change this perception it's important that we share lessons learned.

Lessons learned can be shared in system change reports.

These are reports where organizations write up here is what we heard and

here is what we did.

Event reports also make phenomenal material for safety star and and

good catch programs awarding staff who go above beyond.

And events should be showcased in local publications.

Event reports can also be used to identify

second victims who may need additional support.

Event reports may provide insight into proactive risk assessment topics.

In addition, event reports can be shared externally in publications like the ISMP.

Remember, event reporting is voluntary.

Event reporting is not a valid measure for safety.

It is a signal, not an outcome.

Event reporting practice is sensitive to local culture.

Event reporting alone will not improve patient safety.

We actually have to do something with the event.

Event reports are often peer reviewed, privilege protected and

may come with specific requirements about how the data can be used.

And event reports may require varying levels of organizational response and

types of action.

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