In our current era of transparency, healthcare organizations have been strengthening their event reporting as they strive to improve patient safety. There are many factors to consider when evaluating your institution’s success (or not) in reporting potential safety events. At Seattle Children’s Hospital we have found that the two most important ingredients are a blame-free culture and a robust review system.
Culture
The first ingredient in successful event reporting is to foster a safe environment for staff to disclose errors or problems with the system. This does not happen overnight, and it requires a lot of communication and assurances from hospital and laboratory leaders. Even the terms, “event” and “incident” can be off-putting, as they perhaps have scary or punitive overtones, or mask the intent of the process. At Seattle Children’s, we prefer the word “eFeedback,” and its intentions are clearly explained on our internal staff website (Figure 1). We discuss eFeedbacks daily with staff when issues arise either internal or external to the lab, and supervisors or directors often ask, “Did you eFeedback that?”
We encourage and expect staff at all levels to document concerns, errors, and good catches (or near misses) at the time of discovery. For example, if we report a test result in error and discover it only when a physician calls to question the result, the staff person who takes the call and investigates the problem uses the eFeedback tool—not necessarily the same person who entered the incorrect result. This is important for timely reporting and as a key element of a safe, blame-free environment. In addition, we encourage eFeedback inputters to provide suggestions on how we might prevent similar types of errors. Indeed, eFeedback has a specific section titled Ideas for Improvement, and we have used these suggestions to drive many improvements. Since Seattle Children’s began a refreshed patient safety campaign in 2012, hospital-wide we have seen a doubling of events reported monthly—from about 500 per month to approximately 1,000 per month, of which about 125 per month are lab-related.
Robust Review System
Both our patient safety department and a designated reviewer for each event type review and code each eFeedback entry. In the lab, our quality manager reviews each entry that involves a lab location or specimen—half of which lab staff self-report, and half come from outside the lab. In our review we task division-specific staff or supervisors to investigate the report, while medical directors assess any potential patient harm. We expect files to be closed within 2 weeks, including reports that document follow-up and details of the investigation. Finally, we thank the person who entered the report and provide that individual details of the follow-up when available and appropriate.
The goal of our patient safety department is to assess the degree of harm using Healthcare Performance Improvement standards, which Seattle Children’s employs to assess and report how safe we are as an institution. In cases involving patient harm, the patient safety department decides whether apparent or full root cause analyses are warranted. They then organize a team—including front-line staff—to work through the process and identify steps to prevent such an error from occurring again.
Challenges and Successes
We have had to tweak eFeedback throughout the years. For example, the hospital customized specific event types for various departments, including the lab, to add appropriate fields that help with tracking while also considering the time required to complete an entry. Too many required fields make it onerous for busy, front-line staff to complete in a timely manner. In eFeedback’s current state, it can still be challenging to document some lab-specific events. For example, there isn’t an easy way to handle reporting of a problem with an entire run affecting several patients, because our entry system is patient-centric. We have to use a workaround, entering the issue for one patient, then commenting in the free text field about the additional patients impacted.
Our department relies on eFeedback to help us escalate system-wide issues. For instance, our lab technologists noticed an increasing trend of specimen quality issues (hemolyzed, clotted, quantity not sufficient) collected from the emergency department (ED). We partnered with the ED leadership who requested that we document every ED patient specimen issue. This enabled the ED leaders to identify a correlation between specimen quality and newer nurses. This data demonstrated a need for more education to help our colleagues improve collection practices to benefit patient care. Similarly, we document any patient complaints we receive related to the cost of laboratory testing, to help hospital leaders with their cost transparency initiatives.
Jane A. Dickerson, PhD, DABCC, is co-director of chemistry and director of reference lab services at Seattle Children’s Hospital. +Email: j[email protected].
Amy Henriques, MT(ASCP), is quality, safety, and point-of-care testing manager in the Department of Laboratories at Seattle Children’s Hospital. +Email: [email protected].