Computerized Safety Event Reporting

1
Computerized Safety Event Reporting

• Sandi King, RN, MHAP
• Manager of Clinical Safety
• Safety/Risk Management and Insurance Services
• TriHealth
• Cincinnati, Ohio

2
Overview of TriHealth

• Two Hospital system with 850 beds.
• One inner city facility, one suburban facility.
• Level II trauma centers, Level III Perinatal
  centers.
• Several outpatient services as well as large
  Occupational service line.
• Several rehab centers, a Fitness Pavilion, and
  many physician practices.

3
Access to Information at TriHealth

• Hospitals are linked by same Information System.
• May access records from either site.
• Medical records are partially computerized.
  Working toward total computerization as well as
  CPOE.

4
Project Goals

• Improve the process of reporting all Safety
  Events.
• Educate all staff on reportable events.
• Educate all staff regarding need to report a Near
  Miss.
• Create real time reporting.
• Improve timeliness of reports.

5
Project Goals

• Increase all reporting of Actual Events as well
  as Near Miss Events.
• Include Pharmacy in Medication Event Reporting
  and trending.
• Report identified trends to appropriate
  committees as well as Senior Leadership and
  Operations on a Quarterly basis.
• Ability to benchmark TriHealths two facilities.
• Introduce an Anonymous reporting system.

6
Reporting Goals

• Improve ease of Reporting.
• Decrease amount of time involved as well as
  decreasing paperwork.
• Improve data base ability for tracking and
  trending.
• Communicate significant events and trends to
  appropriate management.

7
Safety and Risk Management Purpose for Safety
Reporting

• To Introduce anonymous reporting.
• To Increase all event reporting.
• To educate staff on the need to report Near Miss
  Events.
• To provide an automated system which all
  employees and volunteers may use.
• Ability to track and trend event data in order to
  institute process improvement.
• To create a change in the Safety Event Reporting
  Climate.

8
Reasons to Report

• Actual Events.
• Near Miss Events.
• Unsafe Conditions.
• Sentinel Events.
• Medical Device Issues.
• Environment of Care Issues.

9
Changing the Climate around Reporting

• Creating an Anonymous Reporting System.
• Educating Leadership and Management on
  Non-Punitive reporting.
• Providing feedback to staff on reported events.
• Reward and recognize best catch reports.
• Educate all staff on System Failure vs.. Personal
  Fault.

10
Steps to Implement Computerized Safety Event
Report

• Create a diverse work team.
• Analyze current paper incident report system.
• Discuss desired outcomes of a computerized
  reporting system.
• Plan corporate wide training.
• Plan implementation.

11
Steps to Implement Computerized Safety Event
Report

• Develop a workplan for Information Systems to
  include the web group.
• Present c.computerized safety event plan to
  Leadership as well as Patient Safety Council.
• Gather recommendations.
• Corporate wide training on report.
• Heavy marketing of report.

12
Security of Safety Event Report

• Present only on TriHealth Intranet.
• May not send out of TriHealth system.
• Reports only sent to Safety/Risk Management and
  Pharmacy.
• Emulation is restricted to Risk Management.
• Ability to store data indefinitely.

13
Members of Safety Event Project Team

• Manager Clinical Safety (facilitator/leader)
• Manager Environmental Safety
• Nurse Managers and staff nurses
• Pharmacy
• Medical records staff
• Information Systems staff
• Medical Director and Physicians
• Lab staff
• Manager Corporate Education

14
Outcome of Safety Event Reporting

• Actual event reporting increased first four
  months by 20.
• Decreased time necessary to complete report.
• Introduced concept of Near Miss Reporting.
• Introduced concept of Anonymous Reporting.
• Included Pharmacy in Medication Events.

15
Outcome of Safety Event Reporting

• Improved tracking and trending ability.
• Ability to benchmark within TriHealth.
• Improved paperless data base.
• Improved process and timeliness of reporting.
• Introduced climate change regarding Event and
  Near Miss Reporting.