Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards

Abstract

Background

Since 1999, hospitals have made substantial commitments to healthcare quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems. Cohesive quality and safety approaches have become comprehensive programs to identify and mitigate hazards that could harm patients. This article moves to the next level with an intense refocusing of attention on one of the individual components of a comprehensive program--the patient safety reporting system—with a goal of maximized usefulness of the reports and long-term sustainability of quality improvements arising from them.

Methods

A six-phase framework was developed to deal with patient safety hazards: identify, report, analyze, mitigate, reward, and follow up. Unique features of this process included a multidisciplinary team to review reports, mitigate hazards, educate and empower providers, recognize the identifying/reporting individuals or groups with “Good Catch” awards, and follow up to determine if quality improvements were sustained over time.

Results

To date, 29 patient safety hazards have gone through this process with “Good Catch” awards being granted at our institution. These awards were presented at various times over the past 4 years since the process began in 2008. Follow-up revealed that 86% of the associated quality improvements have been sustained over time since the awards were given. We present the details of two of these “Good Catch” awards: vials of heparin with an unusually high concentration of the drug that posed a potential overdose hazard and a rapid infusion device that resisted practitioner control.

Conclusion

A multidisciplinary team's analysis and mitigation of hazards identified in a patient safety reporting system, positive recognition with a “Good Catch” award, education of practitioners, and long-term follow-up resulted in an outcome of sustained quality improvement initiatives.

INTRODUCTION

Twelve years have passed since To Err is Human exposed the shortcomings of quality and safety in the United States.¹ Now, over a decade later, hospitals have made substantial commitments to healthcare quality and patient safety through individual initiatives of executive leadership involvement in quality, investments in safety culture, education and training for medical students and residents in quality and safety, the creation of patient safety committees, and implementation of patient safety reporting systems (PSRS). Hospital leadership is involved in executive walkrounds,^2,3 safety culture is measured,⁴ medical students and residents are now educated in quality and safety,⁵ hospital departments have patient safety committees and directors of quality and safety,⁶ and patient safety reporting systems are widespread.⁷ Cohesive quality and safety approaches have become comprehensive programs to identify and mitigate hazards that could harm patients. This article details how continuing quality improvement efforts in a comprehensive program moved to the next level by intensely focusing attention on revisiting and enhancing one of the individual components of the program—the patient safety reporting system.

A MULTIPHASE AND MULTIDISCIPLINARY PROCESS

We envisioned a framework for maximizing the potential of any patient safety reporting system. The goal of this approach was to identify and mitigate hazards using a multidisciplinary team with local oversight of patient safety reporting data coupled with positive public recognition (a “Good Catch” award) for the person or group who initiated the effort to improve safety by reporting the hazard in the patient safety reporting system and then liaised with the multidisciplinary team in the process of mitigating it. We defined a hazard as any potential source of harm.⁸ This framework consisted of six phases: (1) identify the hazard to patient safety, (2) report the hazard in a patient safety reporting system, (3) analyze the report with a multidisciplinary team, (4) mitigate the hazard and educate providers how to avoid the hazard, (5) reward the individual or group who identified and helped mitigate the hazard, and (6) follow up to see if the quality improvement was sustained over time. The following section describes each of these phases, with an overview presented in Table 1.

Table 1.

An Overview of the Process

Process Phases	Activities
1. Identify hazard to patient safety	• Determine that an event has occurred that could harm a patient
	• Clearly communicate the hazard to other members of the patient-care team
2. Report hazard in a patient safety reporting system	• Enter a full report in a patient safety reporting system, documenting the identified hazard
	• Use “SBAR” (Situation, Background, Assessment, and Recommendations) to describe the event in the free-text field
3. Review the report with a multidisciplinary team	• Form a multidisciplinary team to review the report within the specific unit or patient-care unit
	• Invite the individual who reported the hazard to present it to the team
	• Identify factors that contributed to the hazard
	• Determine how the hazard could be prevented from recurring
4. Mitigate the hazard	• Identify individuals who are responsible for mitigating hazards in their respective domains, determine a plan of action, and agree on a timetable for completion
	• Engage hospital leadership to support the team's efforts
5. Recognize an individual or group for identifying and helping to mitigate the hazard	• Present the “Good Catch” award to an individual or group, publicly display the award in the patient care unit with a summary of why it happened and what was done to mitigate it; provide the individual with a certificate signed by hospital leadership to recognize this effort
	• Educate the department or hospital by discussing the patient safety hazard in Grand Rounds, Mortality and Morbidity Conferences, or nursing and medical teaching conferences
6. Follow-up to verify sustained quality improvement	• Track and monitor any patient safety events related to the original hazard
	• Follow-up to verify sustained quality improvement related to each patient safety hazard

Phase 1: Identify a Hazard to Patient Safety

The purpose of this phase was to identify anything that happened in the clinical environment that could threaten the safety of a patient. All members of the patient-care team (e.g., physicians, nurses, technicians, and other hospital staff) were educated to be responsible for recognizing situations or conditions that could lead to patient harm. The existence of any hazard was to be clearly communicated to other members of the team and entered in the patient safety reporting system. These hazards ranged from potentially unsafe conditions, to events in which no harm occurred, to events in which harm or death occurred.

Phase 2: Report the Hazard in a Patient Safety Reporting System

Reporting hazards in a patient safety reporting system preserves relevant information that is necessary to analyze events after the fact and helps to develop a fact-based, appropriate plan to mitigate the hazards and prevent them from recurring.

Many PSRSs have a free-text field in which an individual can enter a structured description of the hazard or event using a simple mnemonic communication tool known as “SBAR,” which stands for Situation, Background, Assessment, and Recommendations (Figure 1).⁹ The SBAR format encourages the individual to organize information about the patient safety hazard into a concise description that includes contributing factors and suggested solutions to address the problem.

Figure 1.

What is SBAR?

Reports in the patient safety reporting system are sent electronically to a multidisciplinary team of providers and staff as determined by the institution.

Phase 3: Analyze the Report with a Multidisciplinary Team

It is important that a multidisciplinary team of stakeholders (e.g., physicians, clinical department administrators, nurses, risk managers, equipment specialists, and managers of clinical operations and information technology) already be designated and functional so that it can review the reported hazard and provide feedback to the specific clinical unit or patient-care area.¹⁰ All individuals who are familiar with the event context should participate in interpreting the hazard (i.e., those who can tease out the various human and organizational factors involved).¹¹ A diverse team can offer a comprehensive knowledge base.¹² For example, explanations given by risk managers on the multidisciplinary team can help practitioners understand the process of prospective risk mitigation as well as the legal considerations involved in risk analysis.¹³ This level of on-site management also cultivates expertise and leadership at the level of the frontline providers. As such, it is valuable to invite the individual who reported the hazard to present the case. This action sends a clear signal to that individual as well as others working in the clinical unit that timely feedback is a priority and that their input is valued.

Phase 4: Mitigate the Hazard and Educate Practitioners

Correcting the hazards identified by clinicians can take many forms. Some may be design-oriented corrections—those that involve physical changes to the clinical environment, such as using different medical devices or repairing code carts. Other corrections may entail altering existing policies and procedures, training or credentialing individuals, standardizing communication, or purchasing equipment and drugs. Depending on which form of correction is needed, the required resources, staff time, and financial expenditure may vary widely. For example, changes to policies and procedures may not be financially costly but may consume staff time; whereas changes to the physical infrastructure can be costly but would not be time intensive for clinicians. Regardless, hospital leadership should be engaged and supportive of multidisciplinary team efforts and participate in activities such as executive partnerships and facility walkrounds.¹⁴ The involvement of leadership and demonstration of the importance of mitigating the hazard can help garner additional resources should they be needed. It is essential in this phase that the multidisciplinary team identifies all individuals who are responsible for mitigating hazards in their respective domains, determine a plan of action, and agree on a timetable for completion.

Grand Rounds, Morbidity and Mortality Conferences, and other quality assurance meetings run by either the department or multiple departments are appropriate forums for disseminating information about the hazard and the steps taken to mitigate it. Electronic communication such as email, bulletins, and other hospital-wide announcements can also be used to generate awareness among practitioners. In addition, the department or hospital staff is educated about the hazard, so that similar patient safety events can be identified in an effort to continuously improve care.

Phase 5: Reward the Individual or Group Who Reported and Helped Mitigate the Patient Safety Hazard

In this phase, based on the consensus of the multidisciplinary team, an individual or group is acknowledged with the positive public recognition of a “Good Catch” award. The main criterion for receipt of this award is that the individual or group who originally identified and reported the patient safety hazard also liaised with the multidisciplinary team and participated in their efforts to analyze the hazard and implement a plan to address it. This award is not given to an individual or group for recognizing and reporting a near-miss incident. Simply reporting a hazard does not improve patient safety if the report does not change practice. Involvement of the reporting individual or group in the activities of the multidisciplinary team creates an understanding that patient safety is everyone's continuing responsibility—a responsibility that is not finished just because a hazard was reported or because a team held a weekly meeting.

Phase 6: Follow-up to Verify Sustained Quality Improvement

Once the patient safety hazard has been mitigated, it is equally important to revisit the issue at regular intervals to verify that the quality improvement has been sustained during the intervening time. Rectifying a patient safety hazard at a particular point in time with a particular group of people without providing continuing, ongoing communication and verification cannot guarantee that the issue remains resolved. If it does not remain resolved, it reverts to being a patient safety hazard again.

OUR EXPERIENCE USING THIS PROCESS

SETTING

We conducted this project in the Weinberg Surgical Suite at The Johns Hopkins Hospital from June 2007 to the present. The Weinberg Surgical Suite is an inpatient/outpatient cancer center that contains 16 operating rooms (ORs), an associated preoperative unit and preoperative evaluation center, a 21-bed postanesthesia care unit, and a 20-bed surgical intensive care unit, in which approximately 6500 high-risk procedures are performed annually. This surgical suite has the Weinberg Perioperative Clinical Services Team (WPCST), a multidisciplinary team comprised of physicians, nurses, risk managers, human factors engineers, administrators, and support staff. The WPCST meets weekly to address perioperative issues related to safety, quality, efficiency, teamwork, and development of new surgical services.¹⁰

Patient Safety Reporting System

The Johns Hopkins Hospital uses the University HealthSystem Corsortium's Patient Safety Net (PSN) as its patient safety reporting system.¹⁵ Patient safety reports specific to the Weinberg Surgical Suite are gathered from PSN on a weekly basis. The director of WPCST (L.M.) selects significant reports (often based on severity) that are added to the agenda for WPCST's weekly meeting. This meeting is 1 hour long and occurs at the same time and day every week. The clinician who reported the patient safety hazard is sometimes invited to present the report to the team, but is always involved with the activities of the team in analyzing and mitigating the hazard.

Implementation

The multidisciplinary WPCST plans and implements Phases 3 and 4 of the process during its weekly meeting. Factors contributing to the hazard are identified and analyzed, and approaches to preventing them from recurring are discussed. Weighted priority score calculations using a tool developed by the team are used to rank hazards so that the team can most efficiently use limited resources.¹⁰ At the conclusion of the meeting, specific action items and a timetable are agreed upon. Follow-up dates are set to discuss progress at the next WPCST weekly meeting.

Minutes recorded by an administrative assistant are distributed by email to the entire team following the meeting. Prior to the next meeting, team members work on their respective action items. Mitigating the hazard at times requires the involvement of and further assessment of the hazard by other stakeholders, such as a human factors engineer, risk manager, or facilities staff member.

Education of Practitioners and Others

In order to educate practitioners in the department or in the hospital as a whole, patient safety hazards addressed by WPCST are presented at departmental Grand Rounds and Morbidity and Mortality Conferences, as well as at nursing and medical teaching conferences. We educate providers using an adaptation of an SBAR report.⁹ This SBAR format has been adopted as the standard approach for presenting at Morbidity and Mortality Conferences which are now routinely used as forums for discussing improvements in safety and educating providers about changes in policies or practices.¹⁶

Selected cases associated with “Good Catch” awards become web-based educational tools, in the form of accessible presentations and knowledge assessment exercises, as well as becoming components of faculty and staff competencies. In our experience, these have been useful venues for disseminating pertinent information about a patient safety hazard, how it was mitigated, and who was responsible for leading the effort. Anesthesiology residents use the process in a practice-based learning course. Resident education, dictated by the Accreditation Council for Graduate Medical Education (ACGME), specifies six core competencies, two of which are practice-based learning and improvement and systems-based practices. We now link each “Good Catch” award to an ACGME competency and educate residents about the systems defect(s) that prompted that award. The strength of this process is that it can be adapted to meet the needs of virtually any group (from undergraduates to cleaning staff) that needs to learn about patient safety hazards.

The Johns Hopkins University undergraduate students provide support for this six-phase process. They collect data on patient safety hazards by reviewing the literature, analyze previous reports from the hospital's Patient Safety Net, assist the multidisciplinary team in investigating patient safety hazards by teasing apart those elements in a system that could contribute to patient harm, draft “Good Catch” awards, and maintain the “Good Catch” award bulletin board in the Weinberg Surgical Suite.

The “Good Catch” Award

To date, 29 “Good Catch” awards have been given to an individual or group responsible for reporting and helping to mitigate patient safety hazards. These patient safety hazards are detailed in Table 2.

Table 2.

“Good Catch” Awards Given To Date

“Good Catch” Award	System Changes Implemented	QI Sustained?
1. Insulin. No standard infusion concentrations	Standardize pharmacy order sheet institution-wide	Yes
2. Heliox. Delayed delivery to OR	On-site OR Heliox	Yes
3. Liposuction. OR personnel unfamiliar with new equipment	New staff in-service	Yes
4. Modified Surgical Stapler. Surgical stapler needed to be modified for innovative surgery	MedSun and FDA report; stapler modification; modified surgical informed consent	Yes
5. Jet Ventilation. Inadequately maintained OR equipment	Daily equipment check	Yes
6. Latex. Outdated latex-free/safe inventory in Weinberg Surgical Suite	Latex-free/safe environment	No
7. CO2 Laser. OR personnel unfamiliar with new equipment	Manufacturer representatives on-site whenever device used	Yes
8. Hysteroscopy. OR personnel unfamiliar with new equipment	Specialty nursing and physician in-service	Yes
9. Methemoglobinemia. Topical anesthetic spray (benzocaine)-induced methemoglobinemia	Limited pharmacy distribution of benzocaine	Yes
10. Heparin. Ordering and distribution of 10,000 units/mL throughout institution	Removal of heparin 10,000 units/mL from institution	Yes
11. 180° Table Turn. 180° table turn for surgical site access delayed reestablishing physiologic monitoring	Safety check initiated by surgeon following table turn	No
12. Vecuronium. Neuromuscular blockade drug look-alike error with antibiotic drug	FDA recall of improperly labeled neuromuscular blockade drug	Yes See #18
13. Informed Consent. Multi-surgeon procedure but only one consent obtained	Individual consent by each surgical service	Yes
14. Rapid Infuser. Resisted practitioner control with unintended alteration of transfusion rate	MedSun and FDA report; institution-initiated equipment change	Yes
15. King LT-D Supraglottic Airway Device. Replaced the previously used Combitube in pre-hospital airway management without informing all providers	MIEMSS updates to inform practitioners; MedSun recommendations with manufacturer input (device lacked identification features for providers)	Yes
16. Double-Lumen Endotracheal Tube. Requested for use in a non-approved patient care unit	Updated policy regarding which patient care units are permitted to use the tube	Yes
17. Transaxillary Robotic Thyroidectomy. Unsafe conditions in new surgical procedure identified	Patient position modified; neuromonitoring recommended with modified surgical informed consent	Yes
18. Vecuronium II.Drug labels noncompliant but pharmacy continues to order due to shortage of properly labeled	FDA notified of noncompliant labels; increased practitioner awareness	See #12
19. Manufacturer-packaged cardiac resuscitation drugs. Look-alike error	Additional color-labeling for these medications when taken out of manufacturer's boxes	Yes
20. Labels on Endotracheal Tubes. Labels are not standardized	Recommended consistent labels; MedSun recommendation to manufacturer (pending)	No
21. Malfunctioning Bed. For patients with BMI > 45	MedSun report submitted	Yes
22. Central Venous Cather Infiltrate. Resulted in hematoma	Risk management review of peripheral versus central vascular access	No
23. Trauma Surgery 911. Difficulty mobilizing surgical attending support during unexpected surgical events	Trauma surgery consulted for OR catastrophes	Yes
24. Intraoperative Blood Cell Salvage for Massive Transfusion Hyperkalemia	Perfusionists wash RBCs for massive transfusion hyperkalemia	Yes
25. Glass Ampules Shattered	Appropriate storage of emergency glass ampule drugs	Yes
26, Lack of IV Tubing Backflow Device. Patient did not receive medication	IV tubing backcheck valve is the standard	Yes
27. Access Jackson Table. Modified by surgeon without risk management knowledge	Risk Management Device Sub-Committee formed	Yes
28. Latex Discovered in Simulation Center	Presence of latex documented; Simulation Center leadership developed protocol for removal and replacement of latex products; temporary signs posted to warn users of specific latex-containing equipment	Ongoing
29. LVAD Patient Harm due to Blood Pressure Measurement Limitations Using Automated Cuffs	Multidisciplinary investigation led to new protocol requiring manual cuff and Doppler being purchased; education of providers about change in practice	Ongoing

Abbreviations: BMI (body mass index), FDA (Food and Drug Administration), IV (intravenous), LVAD (left ventricular assist device), MIEMSS (Maryland Institute for Emergency Medical Services Systems), OR (operating room), RBC (red blood cell)

Individuals honored with a “Good Catch” award have their photographs displayed beside the award on a bulletin board. In the Weinberg Surgical Suite, this board is affixed to the wall immediately inside the operating suite where it is readily seen by all OR staff. In addition, award recipients are given a certificate signed by the executive leadership of The Johns Hopkins Hospital. This certificate becomes a permanent record in each employee's file.

Sustained Quality Improvement

The sustainability of patient safety quality improvements made during this process was tracked over time through ongoing review of all PSRS reports by the multidisciplinary team or by an institutional patient safety committee. Quality improvements associated with 86% (25) of the “Good Catch” awards have been sustained since they were first implemented. Some quality improvements have been sustained since 2008 when the process began, while others were initiated more recently but continue to be sustained as of the date of this article. Quality improvements associated with 14% (4) of the “Good Catch” awards were not sustained; though, to our knowledge, there have not been any recurrences of those patient safety hazards.

CASE EXAMPLES

This section describes in detail two of the cases that resulted in a “Good Catch” award and whose patient safety hazards were addressed using the multiphase and multidisciplinary process described previously.

High-Concentration Heparin

Phase 1

Vials of high-concentration heparin (10,000 units/mL) were found in the Weinberg Surgical Suite satellite pharmacy in a labeled bin containing stocked items. An attending anesthesiologist noted that the vials were substantially more concentrated than the 1000 units/mL and 5000 units/mL vials typically used at our institution.

Phase 2

The high-concentration heparin vials were brought to the attention of our institution's perioperative safety officer for removal and follow-up. The event was reported in PSN.

Phase 3

This incident was immediately assessed by WPCST to determine the reason for the presence of high-concentration heparin and to evaluate the potential safety hazard posed to patients. It was found that heparin is manufactured in vials in low concentrations of 100 units/mL for flushing heparin locks, and in higher concentrations of 1,000 units/mL, 5000 units/mL and 10,000 units/mL, the highest concentration being only for subcutaneous injection. Fatal medication errors have occurred when the 10,000 units/mL heparin was used to flush a heparin lock.¹⁷ According to the Institute for Safe Medication Practices, those errors occurred because nurses were only accustomed to finding heparin vials with 10 units/mL in their bins and the labels of the two concentrations were similar.¹⁸ Subsequently, the manufacturer Baxter revised the labeling on its heparin vials. Heparin errors have occurred throughout the country, including at our own institution and in our insurance consortium (MCIC Vermont, Inc.), when 10,000 units/mL vials were inadvertently used for intravenous injection.¹⁹ Consequently, The Johns Hopkins Hospital and the other MCIC institutions have banned the use of 10,000 units/mL heparin in their hospitals. However, in 2008, Baxter Healthcare Corporation, which produces the majority of the heparin supply in the United States, issued a Food and Drug Administration-mandated recall of 1,000 units/mL heparin vials because of an increase of allergic-type reactions.²⁰ As a result, many institutions were only able to obtain the 10,000 units/mL heparin but believed that individual providers could safely dilute and dispense it. However, providers were not consistently or adequately informed of this situation. In our institution, the 10,000 units/mL vials were inadvertently dispensed to the Weinberg satellite pharmacy. The heparin was correctly labeled by the manufacturer, and the pharmacy bins were correctly labeled, but there was no communication, education, or warning given to providers.

Phase 4

The high-concentration heparin vials and labeled drug box were removed from the Weinberg satellite pharmacy. The pharmacist was notified and immediately investigated other Johns Hopkins OR pharmacies. More of the same high-concentration heparin vials were found stocked and were promptly removed. Operating room leaders were notified and urged to raise awareness among providers and staff. WPCST members communicated with the pharmacy leadership and the director of pharmacies to ensure their full cooperation in creating mechanisms to prevent future entry of high-concentration heparin vials into the pharmacy inventory. The pharmacy staff was re-educated to ensure that 10,000 units/mL heparin vials were not ordered by the institution.

Phase 5

The anesthesiologist who had identified and helped mitigate the heparin patient safety hazard was given a “Good Catch” award.

Phase 6

Follow-up over 1 year showed that this quality improvement was sustained in that 10,000 units/mL heparin vials were no longer being ordered or stocked.

Rapid Infuser Resisted Practitioner Control

Phases 1 and 2

A rapid infuser was being used for safe, high-volume infusion during liver resections. This device is able to infuse large amounts of blood products over a short period of time, as required during this procedure. The Johns Hopkins Hospital's Clinical Engineering Services (CES) received a report from the attending anesthesiologist that a rapid infuser was seen to be infusing at a rate of 500 mL/min, when it had been originally set to infuse at a much lower rate. This incident was reported in PSN.

Phase 3

The WPCST met with CES and sequestered the rapid infuser so it could be tested. They noted that the touch-screen control panel on the FMS 2000 infuser allowed rate adjustments by (a) discrete increments, (b) a fixed selection for 500 mL/min, or (c) via bolus. Three options for touch-screen sensitivity were provided, each option requiring a different duration of contact with the screen to initiate a control action. The device in question was set at “medium” sensitivity; however, the touch-screen controls could not be locked to prevent unintended activation.

Testing the device for approximately two hours indicated that it did not change rate autonomously. On the medium-sensitivity setting, brief, accidental contact with the control panel (e.g., by tubing, fingers or other objects) demonstrated the possibility of unintended control input. CES concluded that in a busy operative environment there could be unintended activation of the touch-screen controls by a moving object. Knowing that a manufacturer-led initiative and/or modification of this device would be the ideal solution for our institution and others,²¹ WPCST and CES first approached the manufacturer. However, the recommendation to revise the touch-screen control panel was not accepted. Subsequently, The Johns Hopkins Hospital submitted a report to MedSun, the medical product safety network administered by the Food and Drug Administration (FDA). The goal of MedSun is to collaborate with the clinical community to identify and solve problems involving the use of medical devices.⁶

Phase 4

To address this patient safety hazard, our human factors engineer designed and then added a hinged, clear acrylic cover above the touch-screen control panel. The cover used a sturdy yet flexible plastic tape as a hinge to provide access for cleaning. The cover provided protection against unintended activation while preserving visual access to display information and enabling intentional control inputs. All rapid infusers of this model in the institution were subsequently modified following this design.

Phase 5

The anesthesiologist who reported and helped mitigate the rapid infuser hazard received a “Good Catch” award (see Figure 2).

Figure 2.

“Good Catch” Award SBAR Summary for Rapid Infuser

Phase 6

In follow-up, this case was presented at a Mortality and Morbidity Conference within the Department of Anesthesiology and Critical Care Medicine. For over a year there been no further issues with the touch-screen control panel of the rapid infuser following this intervention; however, the institution-designed cover on one rapid infuser was damaged and had to be replaced.

DISCUSSION

This multiphase and multidisciplinary process culminating in a “Good Catch” award was applied to 29 significant patient safety hazards in the Weinberg Surgical Suite from 2008 to the present. The resulting quality improvements included modification of equipment (rapid infuser case example), education of providers across the institution (high-concentration vials of heparin case example), changes in the coordination of care, as well as other improvements, including an FDA-mandated national recall of a widely used neuromuscular blocking drug. It is important to note that many other issues have also been addressed using this process—issues that did not qualify as hazards but were nevertheless important to improving the efficiency or effectiveness of care delivery.

This process built upon previous research aimed at learning from patient safety reporting systems. Conceptual models have underscored the importance of four major elements: (1) identification and reporting of events, (2) analysis of the events, (3) analysis of derived results, and (4) development and implementation of process changes.²² Our process incorporated these four elements within the setting of a multidisciplinary team that reviewed local events on a frequent basis.¹⁰ At the end of this process, the “Good Catch” award publicly recognized clinicians for their efforts in reporting hazards and leading initiatives to improve patient safety. Importantly, the “Good Catch” award was only awarded if the precipitating event/hazard underwent our process of multidisciplinary team review, involved of a range of stakeholders, resulted in the development of an initiative to mitigate the original hazard. A similar nonmonetary award tied to specific improvement goals implemented by the Veterans Health Administration demonstrated an improvement in the timeliness and quality of root cause analysis (RCA) reports.²³ While that process was more centralized than the unit-based process we describe, both fostered a culture that valued reporting but more importantly, proactively used reports to drive quality improvement. Though it is not possible to isolate and measure the impact of that process on safety culture, it did positively contribute to safety culture because of its sustainability, as did ours.

Although our process did not, other approaches do use financial incentives, often specifically for medical residents, to influence event reporting.²⁴ That approach may also be effective as it compensates the reporter for his or her time and attention to detail and also appears to reduce negative perceptions of reporting errors and near misses. However, financial-driven or nonfinancial-driven patient safety reports are only as useful as the quality of the information they contain. Simply increasing the number of reports (by financial reward or not) is not meaningful unless (1) the reports contain high quality, relevant information and (2) there is a feedback mechanism in place to use that information toward making sustained quality improvements in patient safety. Closing the feedback loop is one of the most important features of a successful patient safety team.²⁵ We achieved this goal by (1) publicly recognizing an individual or group for their efforts to improve safety, (2) educating the broader clinical community about the hazard and how it was mitigated, and (3) verifying that the quality improvement was sustained over time.

This process had several challenges. Although it has encouraged reporting of hazards and educating practitioners and staff about patient safety hazards, we acknowledge that even more work remains to be done to develop lasting systems and practice changes. Some of the solutions we devised, especially equipment modifications, would have been better served by manufacturerled initiatives, so that individual hospitals do not have to spend resources finding solutions to widespread problems.²¹ Second, the success of this process is limited by the extent of participation from all members of the healthcare team and the sustainability of systems changes. Achieving broad participation and involvement takes commitment and patience. To ensure that the results of the process are sustained over time, it is critical that physicians, nurses, and staff members have access to information about the event and the relevant education and operational safety practices initiated to prevent future harm. We have addressed this issue by using various means to disseminate information pertaining to hazards and actions taken to prevent them (e.g., Grand Rounds and other means, as previously described), but additional avenues of communication should also be considered.¹⁶ Third, this article does not intend to quantify changes in the volume of reports submitted to PSN, as fluctuations in the number of reports submitted is subject to many forces beyond our control (as is to be expected in a busy surgical suite with continually changing staff). Moreover, it is well accepted that data from patient safety reporting systems underrepresent the magnitude of incidents that actually occur, and inferences about change over time based on such data are fraught with inaccuracies.^1,26 Given that all institutions are limited by resources (e.g., time, human, financial), improving the quality rather than quantity of reports by using tools such as SBAR would be a way to improve the use of the reports that are received. Finally, we did not directly measure the impact of this process on safety culture. Several other quality improvement initiatives overlapped with the timeframe of this project and attributing changes in safety culture to any one initiative would be impossible. However, finding ways to correlate or isolate changes in safety culture with specific quality improvement initiatives is an important area for future research as local teams take increasing ownership over quality improvement.

CONCLUSION

An existing comprehensive patient safety program can benefit from a refocusing of attention to the individual component of the patient safety reporting system. The process of using a six-phase framework comprised of a multidisciplinary team to identify, analyze, and mitigate patient safety hazards followed by “Good Catch” awards led to an outcome of long-term sustained quality improvement initiatives at our institution.

Future research can evaluate the change in safety culture using a Safety Attitudes Questionnaire before and after implementation of a process such as the one described in this article. It is our hope that clinicians, risk managers, and administrators will find success in applying or expanding upon the process set forth here for protecting patients from undue harm.