Ebook A Guide To Improving Your Patient Safety Event Reporting Culture Plus A Leadership Action List

eBook
A Guide to
Improving Your
Patient Safety
Event Reporting
Culture
+ a Leadership Action List
American Data Network

www.americandatanetwork.com
P : (501) 225 -5533

E: [email protected]
Learn to Report. Report to Learn.
Patient Safety Occurs at
the Point of Care
With a commitment to caring for and keeping patients safe, it is critical that we evaluate
and learn from every event reported, including those where no patient harm resulted. This
commitment requires a culture of safety that promotes and supports staff in detecting and
reporting incidents, near misses, and unsafe conditions as part of their daily work. Patient
safety occurs at the point of care, making staff the best source for event reporting.
Leadership responsibility includes assurance that staff recognize all types of events and
are supported in their reporting activities. Once near misses and unsafe conditions are
identified, there must be further commitment to taking action through design or redesign,
implementation, and ongoing evaluation of effectiveness for new processes and systems
that mitigate patient risk and injury.
Through event reporting, staff learn to identify high-risk issues that directly impact the
safety of patients.
In order to learn, staff must know:
1 When to report a patient safety event,
2 What constitutes an incident, near miss or unsafe

condition, and
3 Which critical pieces of information are necessary for

assessing the causation and degree of risk or harm that
occurred.
2 A Guide to Improving Your Patient Safety Event Reporting Culture

Event Categories
According to Agency for Healthcare Research and Quality Definitions
An incident is “a patient safety event that reached a patient,

whether or not there was harm involved.” For example, a
patient is administered and ingests an incorrect medication.
A near miss or good catch is “a patient safety event that did

not reach a patient.” For example, the wrong dose of insulin
is discovered by the second verifying nurse prior to patient
administration.
An unsafe condition is “any circumstance that increases

the probability of a patient safety event occurring.” An
unsafe condition does not involve an identifiable patient.
For example, a surgical time-out is not performed or other
features on the surgical checklist are skipped.
A Guide to Improving Your Patient Safety Event Reporting Culture 3

Event Analysis & Causation
Event reporting is essential to identifying, understanding, and addressing underlying
factors and circumstances that contribute to medical errors.
The assessment and aggregate analysis of all events, regardless of severity or harm
levels, is necessary to determine the cumulative risk to patients and highlight splintered
systems and processes that eventually lead to injury.
The goal is to determine what happened, why it happened, and how to reduce the
likelihood of it happening again.
To connect the cause-and-effect relationships and reveal system flaws, start with the
end result (incident) and move backward by asking “why” until the flawed process is
identified as the root. The end is just the beginning of the road to improvement.
The Swiss Cheese Model of causation illustrates that, even though layers of defense
exist within our safety system, the flaws can align and allow the error to occur. This
example quickly exposes multiple failure points that can lead to a fatal patient incident.

Reporting of near misses and unsafe conditions offers the greatest opportunity to
mitigate potential harm before it occurs, as well as foster employee engagement
in safety culture. Near misses and unsafe conditions often occur in larger numbers
compared to incidents and are rich sources of data for learning and improvement. Both
precede patient involvement and can provide warning signs of weaknesses in processes
and systems.
Organizational due diligence is critical in conducting proactive risk analyses of near

misses and unsafe conditions to identify any trends or patterns that warrant priority for
redesign. Additionally, it is imperative that these events are reviewed for any indication
that, without immediate corrective action, would ultimately reach and potentially harm
patients.
The following Swiss Cheese Model is similar to the previous example, but this time
depicts a successful hard-stop safety system that prevents the patient’s arrest and is
reported as a near miss.

Leadership Action List
Every effort should be made to promote a Just Culture approach to patient safety and
support staff in the reporting of patient safety events for prevention, not punishment. Staff
will take a more engaged and empowered role in patient safety when they are encouraged
to participate in the identification and resolution of fractured systems and processes,
becoming subject matter experts and patient safety advocates.
Leadership is recognized as a key factor in creating and sustaining a successful safety

culture and program, including building and promoting a supportive infrastructure.
Strategies to consider include:
1. Create a centralized, coordinated approach to patient safety

2. Embrace a Just Culture, Reporting Culture and Learning Culture
3. Commit to prioritizing safety and making it visible throughout the organization,
including board meetings
4. Measure baseline and ongoing safety culture performance using a standardized survey
tool
5. Develop trust and accountability through an organization-wide, user-friendly electronic

event reporting system
6. Adopt a common set of safety metrics and utilize insights from survey and event
analyses to drive improvements
7. Require education for frontline staff and managers to expose to patient safety sciences
and optimize event reporting for organizational learning
8. Invest in team trainings, resources and technologies devoted to elevating patient safety,
such as Patient Safety Champions, Comprehensive Unit-based Safety Programs (CUSP),
and TeamSTEPPS®
9. Conduct Executive WalkRounds with prompt attention to issues raised by frontline staff
10. Support staff as second victims of medical errors
11. Partner with patients and families to enhance quality and safety

CONTACT US
Get an Event
Reporting Demo
Learning to Report and Reporting to Learn are integral to the success of any patient
safety program. By educating staff on the importance of reporting, analyzing the resulting
patient safety event data, and implementing targeted actions and initiatives, progress
can be made to mitigate risk and injury to the patients entrusted to healthcare teams and
organizations.
Smarter, Simpler Patient Safety Event Reporting Application
The American Data Network Patient Safety Event Reporting Application helps you monitor
and analyze safety events and near misses to improve clinical processes and curb your
organization’s risk. To learn more about the tool or request a demo, contact Susan Allen at
(501) 225-5533.

About ADN
About American Data Network Patient Safety Event Reporting Application
For more than 25 years, American Data Network (ADN), which is also the parent company
to its Patient Safety Organization (ADNPSO), has worked with large data sets from various
sources, aggregating and mining data to identify patterns, trends, and priorities within the
clinical, financial, quality and patient safety arenas. ADN developed the Quality Assurance
Communication (QAC) application, with which hospitals, clinics, rehabs, and other providers
record and manage patient safety events. By entering events into ADN’s QAC application and
submitting them to ADNPSO, information is federally protected and thereby privileged and
confidential. These protections provide a safe harbor to learn from mistakes and improve
patient safety.
We are proud to serve...

Client Feedback
Hear what our customers say it’s like to partner with us.
“Working with ADN has been nothing but a pleasure. My questions and/or concerns are always
addressed timely by an attentive team member with kindness and professionalism.”
Melanie Hedges Draper
Core Measures Coordinator, Baptist Health Medical Center – Hot Spring County
“I appreciate that your team is so knowledgeable and thorough. I absolutely do not regret my
decision to go with ADN! Thanks!”
Marsha Donaldson
Quality & Performance Improvement Manager, Martin Health
To learn more, contact Susan Allen at

[email protected] or (501) 225-5533.

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eBook

American Data Network

P : (501) 225 -5533

In order to learn, staff must know:

1 When to report a patient safety event,

2 What constitutes an incident, near miss or unsafe

3 Which critical pieces of information are necessary for

2 A Guide to Improving Your Patient Safety Event Reporting Culture

An incident is “a patient safety event that reached a patient,

A near miss or good catch is “a patient safety event that did

An unsafe condition is “any circumstance that increases

A Guide to Improving Your Patient Safety Event Reporting Culture 3

4 A Guide to Improving Your Patient Safety Event Reporting Culture

Organizational due diligence is critical in conducting proactive risk analyses of near

A Guide to Improving Your Patient Safety Event Reporting Culture 5

Leadership is recognized as a key factor in creating and sustaining a successful safety

1. Create a centralized, coordinated approach to patient safety

5. Develop trust and accountability through an organization-wide, user-friendly electronic

6 A Guide to Improving Your Patient Safety Event Reporting Culture

Smarter, Simpler Patient Safety Event Reporting Application

A Guide to Improving Your Patient Safety Event Reporting Culture 7

We are proud to serve...

To learn more, contact Susan Allen at

8 A Guide to Improving Your Patient Safety Event Reporting Culture

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