Accreditation Standards & Patient Safety

INTRODUCING A NEW WEB-BASED INCIDENT REPORTING SYSTEM TO IMPROVE STAFF INCIDENT REPORTING(IN A GENERAL HOSPITAL IN KUWAIT)Hossam Elamir, MSc.HCM, TQMD, MBBChQuality & Accreditation Office, MKHInstitute of Leadership, RCSIAhmad Mufreh, B.M., B. ChDepartment of Surgery, ADH

To err is human,to cover up is unforgivable, and to fail to learn is inexcusable.Sir Liam Donaldson

IOM (1999), To Err Is Human: Building a safer health system

The report carried 4 core messages:The magnitude of harm that results from medical errors is greatErrors result largely from systems failures, not people failuresVoluntaryandmandatory reporting programs are needed

Martin A Makary, and Michael Daniel BMJ 2016;353:bmj.i2139Most common causes of death in the United States, 2013

Fig 1Most common causes of death in the United States, 20132

Leape, MD

However, if we were to divide those activities or sectors according to their potential for catastrophe, we could form two groups. One group collates those activities that pose potential risk to individual users but not so much to a social system at large: bungee jumping and healthcare, for example. Adverse events in this group are rather localized accidents. The other group is made of sectors and activities that pose greater risk to social systems. Adverse events are rather catastrophes and put great strains on a system, even to the point of collapsing it (eg, Chernobyl).

sectors or activities that appear as hazardous (such as healthcare), also tend to be less catastrophic and, thus, have a rather individual impact: medical errors and accidents do not cripple a hospital to the point of collapse. This lack of catastrophic consequences may also account for accidental death being more socially acceptable, and for healthcare safety to be less prominent as a social concern. This would also explain why driving, which kills more people than flying, is also a less prominent social concern than, for example, nuclear ships on NZ harbors.Alternatively, if we were to divide those activities or sectors according to total lives lost per year, we can observe that the greatest death toll is carried by sectors and activities engaged by a larger proportion of the population and, even, on a more frequent basis. More people drive or require health care more often than people that fly or work in the chemical or nuclear industries.

sectors or activities which people engage more with are also the riskiest and, yet, also show a less prominent social or individual concern: fewer people engage in bungee jumping and, those who do, probably show a greater concern for their individual safety before jumping than when they drive to the event or go to a hospital.Healthcare safety may portrayed as poor, and a big emphasis (and blame) may be placed on healthcare professionals and healthcare systems. However, this perception of healthcare safety and safety culture may not be fully warranted. Nuclear and chemical industries and mass transport systems are safer because they have received greater attention and resources in lieu of their catastrophic potential, greater social concern and lesser familiarity with.In summary, healthcare may not be as safe as it could, but it cannot simply be compared against aviation or other of the 'safe' activities or sectors. The closest comparable activity in regards to social concern and resources seems to be driving. If we could thus argue that healthcare and, for example, aviation are not comparable in their safety outcomes, is it possible that they are not comparable in regards to otheroutputsand processes, as well?

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Patient Safety freedom from accidental or preventable injuries produced by medical care

Spath, P. (2009). Introduction to Healthcare Quality Management (Chicago, IL, USA: Health Administration Press)

What do literature say?Reporting of patient safety event is universal in healthcare and a backbone of efforts to detect patient safety issues and quality problems.(1,2)Barriers to reporting include lack of feedback and fear of personal consequences.(3,4)

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AHRQ stated that effective event reporting system should have four key elements, among which are protection of the reporter privacy, providing easy accessibility to the reporting system, and timely dissemination of outcomes and feedbacks.(1)What do literature say?

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Our organisational contextIn the 750+ bedded general hospital; which is staffed with more than 3000 employees; the number of reported incidents was 50-80 reports per month.Majority of reporters are nurses (85 %), while doctors are the least reporting staff.

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Our organisational contextMost of the reported incidents are of the no harm errors type. Near misses (good catch) and harmful incidents are usually not reportedWe distributed 35 incident collection boxes allover the hospital, yet, some locations are still not covered.

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Our organisational contextWe interviewed 200 staff; equally representing doctors, nurses, technicians and administrators; to identify the causes of underreporting.Fear of punitive action, lack of feedback and limited access to the manual reporting form were the most common discouraging causes for not to report.

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Flaws of the current systemNot easily AccessibleEnvironmentally unfriendly (Papers, ink)Time & Effort to collectRedundancy in efforts (Data Entry by the nurses instead of the reporter)No Feedback due to anonymous reporting and/or overwhelming workload; If feedback given, it will be in the last stage.

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Some challenges faced with the manual reporting

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The caseOpportunity for improvementPrivate Public PartnershipMultidisciplinary team:Clinician as a reporterQuality Doctor as a managerSenior Programmer

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The Ideal Reporting systemUser friendlyAccessible Anonymous & ConfidentialSecure, HIPPA compliantFeedbacks the reporter at different stagesInstant Notification Permits Easy Statistical Analysis and Exports DataSaves History of ReportsCustomizableAffordableIntelligent Analysis Framework

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ireport-moh.com

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Knowing what happened with your submission

Knowing what happened with your submission contd

The Ideal Reporting systemUser friendlyAccessible Anonymous & ConfidentialSecure, HIPPA compliantFeedbacks the reporter at different stagesInstant Notification Permits Easy Statistical Analysis and Exports DataSaves History of ReportsCustomizableAffordableIntelligent Analysis Framework

Images and Movies can be attached too!

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Thank you Yamco

YAMCO LLC

References:1. AHRQ. Voluntary Patient Safety Event Reporting (Incident Reporting) | AHRQ Patient Safety Network [Internet]. 2014 [cited 2016 Apr 10]. Available from: https://psnet.ahrq.gov/primers/primer/13/voluntarypatientsafetyeventreportingincidentreporting

2. Lawton R, Parker D. Barriers to incident reporting in a healthcare system. Qual Saf Health Care. 2002;11(1):158.

3. Noble DJ, Pronovost PJ. Underreporting of patient safety incidents reduces health cares ability to quantify and accurately measure harm reduction. J Patient Saf. 2010 Dec;6(4):24750.

4. Mahajan RP. Critical incident reporting and learning. Br J Anaesth. 2010;105(1):6975.

Contacts:Dr. Hossam Elamirdr_hossam_elamir@hotmail.com00965 65198442Linkedin: https://kw.linkedin.com/in/hossam-elamir-29697bb2

Dr. Ahmad MufrehDr.shammar@gmail.com0096569999126Linkedin: https://kw.linkedin.com/in/dr-ahmad-m-alshammari-0070b949