Patient Safety
March 7, 2006
Online incident reporting aims to improve patient safety
Out with the old, in with the new. Another system at Dana-Farber is slated to switch from paper to electronic form on April 26, when all "unusual occurrences" will start being reported online.
"Unusual occurrences" are broadly defined as any incidents that do not meet safety standards or the standard of care. Examples include mislabeled lab specimens, unsecured medical records, equipment failures, and, of course, medication errors or patient falls. The Quality Improvement/Risk Management department (QI/RM) receives from 30-40 reported incidents a month; however, "99 percent of them are not clinically significant," says Risk Manager Deborah Duncombe, MHP.
The term "unusual occurrence" will also be an expression of the past. The new online reporting system, called "Safety Reporting," will include all patient and visitor incidents and "near misses." (Employee accidents and injuries will remain on the paper system.) "Near misses" are any failures or errors in a process that are corrected before they reach a patient, and, consequently, provide an excellent opportunity to identify improvement. With March 5-11 as National Patient Safety Week, the announcement of the new online system is another reminder of how Dana-Farber works continuously to find ways to improve patient safety at the Institute, says Duncombe.
"Safety Reporting" is a Partners HealthCare initiative that Dana-Farber has joined. Ultimately, Dana-Farber and all Partners hospitals will use the same online incident reporting system - accessed from a Partners computer application menu - which will allow for across-the-board benchmarking. Brigham and Women's Hospital has been using the system for almost two years. Faulkner Hospital started using the system late in 2005, and Massachusetts General Hospital, North Shore Medical Center, and Newton-Wellesley Hospital are also expected to go online in March, according to Duncombe. Although not a member of the Partners initiative, Children's Hospital Boston also uses the same electronic system.
Making the switch
Currently, the paper system works as follows: Any staff member who witnesses a problem reports it on a standardized form. The supervisor reviews the form, provides follow-up where necessary, and then forwards it to the QI/RM department. A risk manager then reviews all submitted reports, conducts an interdisciplinary review, and tracks the information to determine any trends. Finally, summary reports are compiled from the tracked incidents, which are then submitted to the Joint Quality Improvement and Risk Management Committee, the DFCI board-level group that oversees quality improvement.
The online system will be faster and more direct. A staff member will complete a form electronically, which is transmitted instantly to the staff member's supervisor as well as to all individuals designated for follow-up, including a risk manager and nursing quality specialist. The online form is easy to use with drop-down menu boxes and a minimum number of mandatory fields to fill out, taking only between three and four minutes to complete, says Lisa Martin, Information Services application analyst and the project manager who is implementing the new system.
Because of the ease of the new online reporting, Duncombe says that her group will be emphasizing the importance of reporting near misses. Near misses provide the richest information to help improve patient care processes because so few errors actually reach patients, she explains. Maureen Connor, RN, MPH, vice president for QI/RM, emphasizes that "a major goal of this new system is to increase the number and quality of reports to identify systems improvements for enhanced patient safety."
Training will be available for managers and all frontline staff. The vendor of "Safety Reporting," rL Solutions, will provide instruction for managers, and staff will be able to attend open sessions during designated days in the training rooms of the Smith building, says Martin. The trainings will take approximately a half hour. Those dates, times and locations will be announced on the DFCI Online's announcement scroller as the staff training sessions approach.
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