Above and beyond traditional error reporting
Ensure people are behind the reporting process
As the fourth leading cause of death in the United States, medical errors just don't seem to be going away. Many healthcare professionals agree that reporting such errors is the only way to learn from them and prevent them in the future. But although most medical centers have systems in place for staff to report errors, oftentimes these systems can be difficult, cumbersome, and seemingly void of any real, noticeable results. Inertia and a sense of "why bother?" sets in, further concealing the flawed systems and their lack of a streamlined way to ensure that the causes of identified errors are fixed or improved.
Finding a way to revamp the system of medical reporting might seem just as cumbersome (if not more so) than dealing with what is already in place, but a team of patient safety advocates at the VA Pittsburgh Healthcare System (VAPHS), a three-division, integrated healthcare system that serves the veteran population throughout the tristate area of Pennsylvania, Ohio, and West Virginia, decided to establish an alternative method of reporting errors called the Patient Safety Triage Committee (PSTC). Using available technology and anonymous reporting, the PSTC was able to create open dialogue with frontline staff in an effort to increase reporting of safety issues, create opportunities for improvement, and solicit innovative ideas to enhance patient safety throughout the medical center.
David Eibling, MD, physician champion of the PSTC and an ear, nose, and, throat physician at VAPHS, along with Lynda Brettschneider, RN, MSN, patient safety manager for VAPHS, created an eight-person, interdisciplinary, physician-driven committee made up of nursing staff, facility engineers, pharmacists, and other mid-level providers who encourage staff to report safety issues anonymously. Once reports are submitted, the committee evaluates and triages those patient safety issues and reports them to leadership on a quarterly basis, acting as a middleman between staff and leadership and forming an unofficial, confidential, and parallel system to the facility's official reporting system.
"The idea was to keep it small and to put people on the committee who were not in a supervisory role to encourage reporting," says Eibling. "If we have a need for expertise in another area, then we go out and seek that person, even though they may not be members of the committee. We still borrow their brains."
It all started when Eibling, who happens to be a former member of the Air Force, got angry.
"I got angry over the fact that it seemed we were focusing all of our efforts on things that didn't matter and missing the things that did matter," he says. "I said, ‘We need to help the hospital leadership in triaging patient safety issues.' We attempt to identify for hospital leadership what the issues are that need to be addressed right now, what the issues are that we should put our emphasis behind, what are the ones we can sort of deal as a hit-and-run and just keep going, and what are the ones beyond our ability to fix."
In any high-reliability organization, the emphasis on reporting is so important that it has been identified as one of the major indicators of a positive safety culture, says Eibling. The poster child for such a culture is the aviation industry, and the PSTC has tried to adopt some of its well-known characteristics, such as reporting in a manner that is blameless for the reporter. "So, if you're a pilot, and you make a mistake and you report it, all of that data that is identified is managed by NASA, not the Federal Aviation Administration [FAA], because the FAA is the licensing and certifying agency," says Eibling. "The aviation industry leadership was smart enough to realize you have to separate safety reporting from licensing, or people won't report. What we tried to do was develop an alternative way in which folks can do that."
Identify the barriers
Brettschneider says that she and Eibling want the committee to function as a way to identify opportunities for improvement in patient safety, contribute to a culture of safety, and ultimately bring about change; however, she notes, the first thing you have to do is identify the barriers to that change.
One of the barriers has been the difficulty of reporting, says Eibling. "For example, this morning I filled out an incident report in the original system, which is quite complex, and it took me several tries to get it right. In fact, I still wasn't sure if I did it right, so I called Lynda to make sure it made it in."
Another barrier to reporting errors is called "the black hole effect," in which people ask why they should bother reporting because they don't see the effect of their reporting (i.e., the reports end up in a black hole).
Eibling says he sees this effect most in his facility's residents. "Residents are the ones who are at the point of care, where they're most likely to see threats to patient care. They say, ‘I'm just here for three months; nothing is going to change anyway, so why should I take the time to report?' They're like renters, not owners. So part of what we've been trying to do is to tell them that they can make a difference," he says.
Brettschneider and Eibling knew that for the PSTC to be effective, they would have to make it easy. They established two alternative reporting methods to the original system: first, a simple point-and-click intranet website safety report that is accessible through the medical center home page, and second, a patient safety hotline. The intranet safety report is automatically transmitted to the PSTC, and the patient safety hotline messages are sent directly to Brettschneider. Both reporting mechanisms are reviewed daily, and the PSTC either resolves the safety issue immediately or redirects the issue to other medical center committees.
For larger issues, the PSTC meets monthly to review and prioritize all the data for leadership to discuss, and to decide whether certain issues need a team approach. "For example," says Eibling, "at the last leadership meeting, it was elected to take one of the particular safety issues regarding discharge medications, and ask the veterans engineering design center to take the project, because it's an important project and it needs highlevel attention."
The meetings are simple and have a straightforward mission. "All we did was say, ‘Here are the issues, here are the ones that are important, and here's what we think you ought to do.' " says Eibling.
Buy-in from leadership has been key to the committee's success. "The VAPHS leadership is an advocate for patient safety and anything that could be done to change for the better. They helped push it along. Unless you have leadership, this is not going to work; any safety initiative is not going to work," says Brettschneider.
Empower the reporters
But how does the PSTC empower people to report in the first place? Brettschneider says that she makes a point to talk about reporting monthly at new orientation and nurse manager unit meetings to get the word out. People have been stopping by her office, calling her on the phone, and sending her e-mails to alert her to issues-all signs of moving toward a more positive culture, she says.
One of the things both Brettschneider and Eibling have learned from creating this committee is that culture is hard to change and that it is difficult to induce people to think differently and accept the fact that change is possible. What makes the PSTC reporting system unique is that reporting is simple, and doing so creates an open dialogue with frontline staff to develop patient safety issues. The idea behind the committee was that it empowers people-shows them that there is something they can do-and encourages them to look for and think about safety issues, they say.
The PSTC also encourages people to report by providing them with the opportunity to be a part of the solution, which Brettschneider thinks is an incentive in and of itself. "People want to do things the right way. It's the systems and processes that we put in place that ultimately hinder that," she says.
Eibling echoes Brettschneider's assessment, saying that people already know what is right and what needs to be done. Seeing results and improvement persuades them to report more.
"Their goal is to make things better, and that is enough of a reward, especially if they believe they are actually making a difference," he says.
See the results
In an effort to directly encourage people to make a difference, the PSTC has recently started implementing patient safety rounds-actually going out to visit with nurses and providers at their workplace and asking them three questions: "If an injury were to occur on your unit:
- Who would it be? (no names)
- What would be the cause?
- What could you do to prevent it?"
By doing this, the PSTC gives people the opportunity to be a part of the solution while keeping the process simple and straightforward.
The VAPHS has seen a number of results, including the ability to measure which areas see the most issues and prioritize those areas effectively. Since the committee was formed, the PSTC found that between August 2009 and April 2011, 50% of error reports were patient safety issues, 20% were environmental issues, 16% were general safety issues, 8% were radiology issues, and the remaining 6% were infection control issues. Armed with this new information, a number of actions were taken to fix these issues.
Receiving reports is not the end of the error reporting process, says Eibling, but the beginning of quality and process improvement.
"This journey is just beginning and we've been at this for two and a half years. Inducing this culture for reporting is a lengthy process," says Brettschneider.
As a result of making the reporting process simple, making it fit into staff and process work flow, and encouraging staff to report immediately at the time of an event, Brettschneider has watched the team grow and change as more people express the desire to participate in the committee itself.
"It's there," she says, referring to the will of the staff. "It's just being patient, being able to help them come to the [realization] that we can make a difference and we can change things for the better."