How Healthcare Leaders Can Prevent Fatal Errors
Barriers to event and incident reporting can all deter healthcare employees from sharing their observations. But for patients to receive the highest quality of care possible, reporting must become a proactive undertaking, rather than one that collects or performs analysis only after harm occurs. Read on tolearn how to encourage healthcare teams to report incidents andwhat can be learned in the process.
The entertainment industry has in recent years brought medical mistakes and tragedies to light. The series “Dr. Death,” for example, is based on the gross malpractice by a former American neurosurgeon who was sentencedto life imprisonment. The documentary “ToErr is Human”explored worst-case scenarios of medical errors and the culture that continues the problem.
Unfortunately, medical error and harmful patient safety events aren’t just the focus of movies andpodcasts. They are very real issues in the healthcare industry today. Estimates vary, but preventable U.S. hospital deaths annually have runin the hundreds of thousands in recent years – a number that’s expected to grow if our systems do not change.
Many hospital deaths and patient injuries could be prevented with better reporting by healthcare workers about patientsafety issues. By increasing the reporting of near misses and unsafe conditions, healthcare organizations gain a greater understanding of their safety challenges and prevent future harm.
About 86% of patient safety incidents occurring in healthcare organizations go unreported, according to a study released by the U.S. Department of Health and Human Services.
Barriers to reporting – such as fear of blame or retaliation, lack of understanding about what qualifies as a safety event or near miss, and the complexity of the reportingprocess – can all deter reporting. But forpatients to receive the highest quality of care possible, reporting must become a proactive undertaking, rather than one that collects or performs analysis only after harm occurs.
How to increase reporting
Below are some strategies on how to encourage healthcare teams to report incidents and what can be learned in the process.
Emphasizeanonymousreporting.With many patient safety events going unreported due to fear of blame or retaliation, anonymous reporting can help organizations place the focus back on patient safety and shift from a culture of blame to one of encouragement. The result is a culture that identifies systemic and root causes, learns from reports, and takes targetedactions to prevent future occurrences. Anonymous reportingcan increase the number of reports submitted by decreasing the fear of negative repercussions and other incentives to hide information.
Lowerthereportingthreshold. The great value of reporting near misses and all incidents is not just that they provideorganizations with a more complete picture ofwhat risks may exist, but also that they encourage even more reporting among staff. Within a culture of safety, reporting is destigmatized.
Clarifythatallrelevantfactorswillbeanalyzed. When staff members are convinced that near misses and incidents are the product of multiple factors and that all contributing factors will be
considered during analysis, they will understand patient safety to be the responsibility of entire care systems rather than individuals.
Conductlogicalanalysesaimedatactionplans. Employees will have greater trustin the process if there is a thorough review of all contributing factors and underlyingcauses, such as understaffing, poor system design, and faulty equipment. When action plans address relevantissues, an organization demonstrates its commitment to long-term results rather than short-term fixes.
Sharetheresultsoftheprocess. Key action points should be shared with clinical staff and regular training should emphasize a team-based approach by outliningsome incidents and discussing both their causes andchanges made toprevent the recurrence. Reporting succeeds when results are communicated through system improvements.
Many of us in healthcare entered the profession because we wanted to help, heal, and serve. Atour core, we have compassion, empathy, and a drive to help people live their best lives.
Recognizing and implementing actions to prevent patient and employee harm has the greatest potential effect onthe quality of care delivered inour healthcare system, just as preventative care and wellness efforts slow or stop the progression of disease.
In my soon-to-be-launched book, “Shared Voices: A Framework for Patient and Employee Safety in Healthcare,” I explore how hee leaders can create organizational structures centered around reporting incidents and near-misses, then use systems thinking to resolve and prevent patient and employee safety events. Learn more and order your copy here.
A version of this article originally appeared on Nashville Medical News.
