[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.
