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Clinical Consultation: Patient Safety: The Changing Face of Error Reporting
Situation: This article explores the ways in which medical error reporting is evolving in response to the increased focus on patient safety. It gives an example of a “near miss” incident, why it would be reportable, and what the benefits of reporting might be. The material presents the importance of involving the rehabilitation nurse in recognizing and reporting events, as well as the invaluable contributions that the hands-on rehabilitation nurse can make to reduce patient risk, improve system processes, and increase patient safety.
Consultation: Sharon Saracino, CRRN, a patient safety officer at John Heinz Institute of Rehabilitation Medicine, Wilkes-Barre, PA, replies:
Mrs. Johnson is a 64-year-old patient who was admitted with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD). While participating in an uneventful physical therapy session, Johnson developed severe respiratory distress and chest pain. The physician ordered Johnson’s transfer to the emergency department (ED) of an acute care facility for an evaluation. While the nurse continued to monitor the patient pending the arrival of the paramedics, the unit secretary copied the medical record and medication administration record to accompany the patient.
During this acute event, two patients arrived on the unit for admission and one patient was awaiting discharge. The secretary inserted the copies in an envelope and the nurse completed and included the emergency transfer sheet. The patient was transferred via paramedic unit to the ED, for further treatment. Shortly after arriving at the ED, the hospital staff reviewed the patient’s records and noticed that the medication administration record was that of another patient. The ED staff contacted the rehabilitation staff regarding the error and the correct medication records were immediately faxed to the ED. The patient did not receive any incorrect medication. Is this a reportable incident?
Focus on Patient Safety–Mandatory Error Reporting
In recent years, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and Pennsylvania’s State Department of Health have made patient safety a primary focus. With the publication of the proposed 2006 JCAHO National Patient Safety Goals, it appears that this trend will continue as we search for the safest way to provide the highest quality health care possible.
The Pennsylvania Patient Safety Authority (PSA) was established by the Medical Care Availability and Reduction of Errors Act of 2002 (Act 13). This agency is charged with taking steps to help reduce medical errors and promote patient safety in Pennsylvania’s healthcare facilities. The Pennsylvania Patient Safety Reporting System (PA-PSRS) is a mandatory, confidential, statewide information system for reporting events and situations that have, or could have, resulted in unanticipated patient injury. This system was developed by the Pennsylvania PSA to aid in aggregating and reviewing the types of medical errors occurring in Pennsylvania’s healthcare facilities, identifying problems and trends, and recommending solutions.
More than 400 healthcare facilities are now reporting through PA-PSRS, the first such error reporting system of its kind in the United States. Since June 2004, the PSA has received more than 100,000 reports. It has issued several advisories based on the information contained in the reports that then allow individual facilities to examine their own processes related to the identified problems. Reports that are entered into the system as serious events are concurrently reported to the Department of Health, eliminating the need to file separate reports.
A Cultural Shift
After years of looking at who made the error and who was at fault, we now must be prepared to shift the focus to why the error occurred. Even if management has made the commitment to revise the past perception of the causes of medical errors, convincing staff may take more effort. Cultural change does not happen overnight. A facility can only develop a culture of safety as a result of each person making an effort to take a different approach. Patient safety bulletin boards, newsletters, staff incentives and rewards for reporting near misses are some ways the John Heinz Institute of Rehabilitation Medicine has found helpful in shifting the focus from blame to process improvement. Reviewing trends during general staff meetings is another way to raise awareness of the types of errors that are occurring, as well as to process improvements that have been made to minimize the potential for future occurrences.
Benefits of Increased Reporting
Experience may be the best teacher, but one of the best ways to reduce medical errors is to analyze the circumstances of close calls or near misses and identify what factors contributed to the medical errors.
Establishing a culture of safety where staff feel comfortable reporting both actual adverse effects and near misses without fear of punishment or retribution is key to creating a culture conducive to patient safety.
Only by emphasizing proactive risk reduction and focusing on health care as a system can truly meaningful improvements be made. Reinforcing a systems approach that looks at errors as a way to improve processes (as opposed to a cause for blame and chastisement) encourages staff to report actual events as well as near misses. Such reporting enables healthcare facilities to troubleshoot for patient safety risks and then reform the processes to reduce those risks.
As for Johnson, our facility would report this event. Although the patient suffered no harm, the potential for harm existed. While investigating the incident, we would review the process currently in place for emergency transfer situations in which staff was involved, and what was happening concurrently on the unit. We might also conduct a root cause analysis, inviting staff from the receiving facility to participate to gain insight into their processes and improve the transition between the two facilities during emergency situations. Document revisions, checklists, and double checks could be implemented to reduce the likelihood of a recurrence. So although the patient was not affected, reporting this near miss allows us to identify a problem and to develop a system to reduce the risk for future emergency transfer patients.
Where Do We Stand?
Our facility is less than 1 year into the mandatory reporting system of the PSA and attempting to establish a cultural change. Are we there? Not completely, but we have made progress. Focusing on patient safety is a priority and an ongoing process. We continue to challenge ourselves to improve our existing systems and processes. Even working within an ideal system, none of us is infallible. We can help, however, to reduce the levels of risk, make a difference, and improve our patients’ safety and quality of care by reporting medical errors and near misses.
Staff Involvement Is Key
In today’s healthcare climate, rehabilitation nurses face challenges that may seem overwhelming. Increased patient loads, higher acuity levels, staff shortages, and declining reimbursements for rehabilitation care have all played a part in contributing to staff fatigue, frustration, and medical error. But as professionals, our focus has always been patient safety and quality of care. Even in this climate where there are never enough hours in the day, our staff is now taking time and reporting more events than ever before. They have become more attuned to what could happen, not only to what has happened. In addition, they are less inclined to “write it up” and move on and more inclined to offer suggestions as to what they feel went wrong and ideas for improvement. Our rehabilitation nurses are on the front line of patient care. Their perceptions of our processes and systems provide valuable insight into the means for improvement. Promoting a nonpunitive reporting process and recognition of staff contributions not only gets staff involved, but also develops safe and effective changes.
About the Author
Sharon Saracino, CRRN, is a patient safety officer at the John Heinz Institute of Rehabilitation Medicine in Wilkes-Barre, PA.