To improve patient safety, we must follow the patient. Healthcare incident reporting, also known as event reporting, used to be about tracking adverse events in hospitals. But hospitals are no longer the center of the healthcare delivery universe, patients are.
As providers increasingly administer care and services in outpatient or retail clinics, specialty centers, and via telemedicine, our patient safety and quality improvement tools must adapt as well.
Incident reporting is a part of incident management
Incident reporting is the act of documenting all incidents, near incidents, and commendations. Ideally, it employs an online form and workflow to capture details and share the account digitally. Incidents are also reported through other means such as complaints, audits, and safety rounds. Robust web forms allow for customization, display only relevant questions based on incident type, enable anonymity, and support attachments such as photos, videos, or voice recordings. An incident report should be completed at the time an incident occurs and as the organization’s policies dictate, no matter how minor an incident may appear.
Event reporting provides valuable insight into adverse events that compromised patient safety—or could have. It helps to identify the root causes of incidents to prevent future ones, which directly contributes to improving healthcare safety and quality. And research has tied physician burnout to lower-quality, unsafe patient care, increasing the importance of learning from incidents.
No matter what healthcare incident reporting tool is used, it must support risk management across your health system. What should truly integrated event reporting look like? And how should it respond to the changing landscape of care delivery?
Educate & train hospital staff on the importance of incident reporting
You can’t get far in encouraging accountability for quality improvement where there’s fear, blame, and uncertainty about the impact of event reporting. Staff education and training enables all parties involved in risk reduction to understand that human error and technology failures can occur despite our best efforts. However, we must be constantly vigilant against mistakes and strive to improve safety, learning from adverse events and errors.
In educating and training staff, emphasize the organizational goals of transparency, data-driven methods, fairness, collaboration, and the pursuit of excellence. Avoid these common hurdles that erode a positive environment for event reporting:
- Using the same process for minor and important events
- Labeling incidents (bad vs. good)
- Allowing misuse of findings internally
- Failing to help staff improve once events are documented
Transparency in incident disclosure
A recent study showed that in hypothetical situations, 90% of the healthcare providers polled (538 medical students, residents, and physicians) said they would disclose medical errors. But in real circumstances, only 41% actually reported doing so. Such statistics beg the question: What’s holding back our practitioners and organizations from 100% disclosure?
Just Culture’s aim to manage behavior and design systems that allow anonymity to encourage openness established a promising start. symplr's solutions are at the heart of discovering and correcting discrepancies that impede progress in promoting safety.
Effective patient safety and continuous quality improvement efforts that result in fewer incidents will require continued:
Transparency provides a path for collective research into wider prevention of errors based on aggregated data. In the past, concerns about liability, discovery, peer review protections, and privacy concerns have resulted in reluctance or outright refusal to disclose incidents, effectively isolating the data in one facility or system.
Automate healthcare incident reporting for safety, access, and accuracy
Event reporting starts with documentation for the simple fact that time erases crucial details. Paper reports are a good start but don’t enable organizing, sharing, and reporting on key findings that could save trouble down the road. Staff can’t proactively promote patient safety strategy unless they are part of the analytical process.
If we’re going to follow the patient to effectively prevent harm, our safety tools must be accessible and built for all parties who share in the responsibility to track and report healthcare incidents—patients, providers, staff, visitors, or any other personnel. Automation reminds busy clinicians with alerts or triggers when they have a role in documenting or analyzing an adverse event. Accessibility also encourages “see something, say something” actions by patients or visitors, anonymously or not.
Automation yields valuable big-picture insights into processes or events that could compromise patient care. Specifically, event reporting software performs analyses to show patterns of risk or details missed when technology isn’t employed or it’s not easily accessible. Automation also means integration. Peer review, OPPE, and FPPE pull data from multiple sources including case reviews. Why not use a system that makes the connections for you?
Last but not least, healthcare incident reporting software instills confidence that valid information is collected in a timely manner. To foster positive change across your integrated healthcare system, make your event reporting tool accessible and capable of processing essential information documented during the first crucial hours and days post-event. Longer term, keep track of every detail for records and liability protection.
What constitutes a complete incident management strategy?
A total incident management approach provides the processes and tools to track a healthcare grievance or complaint from registration through analysis to outcome. It will identify, for example:
Alternatively, a well designed incident management strategy is capable of recognizing an individual’s positive contribution to safety by acknowledging the action. It’s indisputable: Improving our healthcare system also requires recognition of what we’re doing right, not just identifying the failures or near misses.
Finally, a complete incident management strategy will provide insights across the often disparate functions of:
Must-have safety and event reporting functionality
Look for a web-based event reporting software that accomplishes what your organization needs today and may need down the road for incident data collection and analysis. Compare any solutions considered with symplr’s robust functionality:
- Privacy and security safeguards for individuals involved in the event reporting process. Data is accessible only to authorized users. You decide how events are reported, whether anonymously or not, whether the practitioner is notified, and if reported events are linked to peer review cases.
- Create an unlimited number of action items that can be used for notifications and follow-up. Send notifications of reported events by email or text to participants or key personnel. Users can manage their event notifications by indicator and facility or location.
- Quickly run and export incident reports for trending and tracking. Choose from standard reports or configure facility-specific reports that can be accessed from anywhere on any device. Create high-quality reports or analyses that are presentable to hospital administrators, governing bodies, payers, and accreditors and regulators.
- Integration with your hospital’s provider data management software—such as credentialing, privileging, and peer review including FPPE and OPPE.
- Ability to configure events/incidents and required information using indicator choices and severity levels. Track indicators, including multiple indicators, on one event.
Four analytical methods for reported incidents
There are numerous methods to analyze a reported incident to reveal the fundamental cause(s) and/or limit the effects. The following common approaches differ in the degrees to which the incident information is examined and classified:
1. Systematic Incident Reconstruction and Evaluation (SIRE): Focused on incidents with serious consequences or those occurring frequently, SIRE offers multiple means of analysis: timeline, process, and barrier. This method is considered labor intensive.
2. Ishikawa Diagram, also known as a fishbone diagram: This method entails drawing a cause and effect diagram to identify cause in roughly three steps: name the problem, describe the major causes, divide the major causes into sub-causes. Its advantage is its accessibility.
3. Prevention and Recovery Information System for Monitoring and Analysis (PRISMA), also known as root cause analysis: PRISMA analysis requires mapping incidents visually using a “cause tree” to show underlying factors and circumstances. Its advantages include the ability to conduct in-depth analyses and to identify patterns of root causes to deploy targeted improvement actions. PRISMA has demonstrated positive influence on staff willingness to report incidents.
4. Failure Mode and Effects Analysis (FMEA)—also known as prospective risk analysis: This systematic and proactive analysis uses a flow chart as part of four steps to analyze as many products, services, and processes as possible to identify potential failure modes and their causes and effects. Its disadvantage is its focus on the how and why of failure, not on whether something will fail. In addition to estimating impacts, it can be used to help limit their effects.
5. Functional Resonance Analysis Method (FRAM): The Safety II method is an example of FRAM, which describes outcomes by analyzing variability in performance. It maps the difference between policy and practice by examining daily activity, analyzing workplace situations, and capturing how individuals react when deviations occur. Its advantages include transparency and a focus on prevention. However, not all actions can be recorded in procedures, and procedures aren’t always followed.
symplr’s solution supports multiple analytical methods, recognizing the need for flexibility in an incident management platform.
symplr can help your hospital track cases and healthcare incidents that are attributable to your providers and staff, and which may impact patient care, safety, reimbursement, and quality. Learn more about symplr’s safety and compliance solutions today.