Implementing a Patient Safety Reporting System

When implementing a patient safety reporting system, consider these seven factors, which will influence your system’s effectiveness.

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Since 1999, when the Institute of Medicine published its landmark report, “To Err is Human,” healthcare executives have waged an all-out war on reducing preventable patient harm.

The worldwide commitment to patient safety has included investments in safety culture, the creation of patient safety committees, and the implementation of patient safety reporting systems, also known as incident reporting systems. It is the latter that has allowed healthcare institutions to make the greatest gains in improving patient safety.

While incident reporting systems are relatively new to healthcare, they have been a cornerstone for improving safety in other high-risk industries, including aviation and nuclear energy. The idea behind all incident reporting systems is relatively simple – they provide a mechanism to identify risks before these risks result in harm. They also offer valuable learning opportunities that can be spread through the organization. In healthcare, such a patient safety reporting system can provide frontline staff a way to report issues and potential risks that the leadership team can then work to mitigate.

7 Factors to Consider

When implementing a patient safety reporting system – or any enterprise risk management plan – consider these seven factors, which will influence your system’s effectiveness.

  • Psychological Safety: Staff need to feel safe when reporting incidents and raising concerns. If they feel they will be punished for submitting incident reports, then the number and quality of reports will diminish, along with opportunities for reducing preventable patient harm.
  • System Alignment: Appropriate systems and processes must be developed in order to effectively and efficiently assign and prioritize incident reports and follow them through the entire investigative cycle.
  • Human Resources: In order to ensure that patient safety reports are thoroughly and correctly investigated, the organization needs experienced and appropriately trained incident investigators.
  • Data Analysis: Systems and processes must ensure contributory factors are recognized and data is effectively analyzed to identify patterns and trends.
  • Appropriate Interventions: The patient safety reporting system must ensure that recommendations, interventions, and improvement strategies are evidenced based, resource effective, and implemented in a controlled manner.
  • Effective Oversight: Once improvement strategies and interventions are identified and implemented, appropriate monitoring is required to ensure that improvements are sustained.
  • Effective Communications: To create a culture of learning and continuous improvement, staff must be kept informed of improvements and provided with feedback relating to how incidents and patient safety concerns have been addressed.

While these seven factors seem obvious, the unfortunate fact is that most patient safety reporting systems are still new and focus primarily on reporting events through an incident reporting form and template. To enhance the value of any patient safety reporting system, we must go beyond the simple reporting of events and mine our patient safety data to identify risks of patient harm, prioritize where to focus resources, develop interventions to mitigate these risks, and evaluate whether our interventions achieve desired results.

How Datix Has Solved This Problem

To ensure that healthcare organizations maximize their patient safety efforts, we built into our software a quality improvement loop that ensures the above factors are addressed. Both DatixWeb and Datix Cloud IQ include modules than enable the capture, evaluation, strategy development, implementation, and assessment of patient safety incidents.

What’s more, Datix Cloud IQ allows organizations to go one step further; as issues are uncovered and improvements are implemented, organizational procedures are updated to embed the changes. As a result, organizations are able to not only hardwire the seven factors for a patient safety reporting system into daily operations, but also have a memory of what improvement initiatives worked and why.

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We will respond to your query and deal with your personal data in accordance with our Privacy Policy. If you are an organisation already benefitting from, or likely to benefit from, Datix’s products and services, we may get in touch with you to consider this further.