CMS stated that other patients were at risk.
After the patient in the hospital’s psychiatric unit repeatedly got out of bed and wandered the hallways, staff members physically restrained the patient facedown, according to the CMS report obtained by Modern Healthcare. The patient ultimately suffered cardiac arrest and died.
If you don’t think this could happen at your hospital, think again. In fact, the CMS report identified other instances where staffers at this hospital didn't follow proper restraint procedures, although no other fatalities occurred.
CMS has required the hospital to submit a corrective action plan; without one, the hospital is in danger of being kicked out of the Medicare program – which would bring significant financial hardship to the facility.
Certainly, the corrective action plan will outline new policies and procedures, staff training, and – hopefully – incident reporting.
It is this last item on which we want to focus.
A Culture of Self-Reporting
Protecting patients from harm requires active surveillance within a safety culture that encourages self-reporting of errors and near misses. If we don’t make it easy to report, or if our culture is a punitive culture that prevents reporting from occurring in the first place, then what happened at this Tenet hospital can happen anywhere.
It is for these two reasons – ease of reporting and a “just culture” – that Datix has invested over the years countless hours and hundreds of thousands of dollars working with our clients to better understand how to improve rates of reporting and ownership of risk.
The results of our efforts – and the efforts of our clients – are paying off handsomely.
For instance, our online incident reporting form has been designed in consultation with our users so that it is simple to use and suitable for both clinical and non-clinical incident reporting. The user interface can be personalized to your needs, and the workflows can be amended to match your organizational structure. Incidents can be submitted by anyone in your organization at any time. All they need is access to a computer.
One Hospital’s Findings
This is more than simple rhetoric. Recently, one of our hospital clients, after implementing DatixWeb as part of its zero patient harm initiative, discovered how much easier it was to record accurate and meaningful data, which enabled robust incident reporting. The dashboards we built for this client quickly conveyed important patient safety intelligence, with email notifications giving real time alerts to clinical managers. What’s more, because the software provided actionable information – which was now being used by hospital leadership to improve quality and patient safety – and staff could see tangible improvements resulting from the zero patient harm initiative, the number of incident reports being submitted annually increased by nearly 15%. That’s not a typo.
Imagine if Tenet had such an incident reporting program in place across its system – maybe it does, but it’s still worth spending a moment reflecting on the impact such a program can have on a system such as Tenet.
Tenet currently operates 68 acute care hospitals, 21 surgical hospitals, and 460 outpatient centers in 47 states. They have 115,000 employees, 32,000 active physicians, 33,000 nurses, 11 million patient encounters annually, and $19.2 billion in annual revenue. They are No. 147 on the Fortune 500 list.
In other words, they are a force in healthcare.
With a system-wide incident reporting program, imagine the leaps forward that Tenet can make to improve the quality of care and reduce preventable patient harm. Imagine the trends that can be identified across these 11 million encounters that can have a profound impact on patient outcomes – trends that would otherwise never even blip the patient safety radar screen. And imagine the leadership position that Tenet can take in driving incident reporting improvements worldwide.
Because if Tenet can implement an integrated incident reporting program across a system as big and cumbersome as Tenet, well, then certainly every other hospital can do so, too.
We’re hoping Tenet takes the lead on this. And we’re also hoping that they ask us to be their partner in this endeavor.
We’re waiting for the phone to ring. And if the call that comes in is not from Tenet, but instead it is from you, wanting not to wait for someone else to take the lead, then we’re eager to have the conversation.
Call us at 312-724-7776 or click here to connect with us online.