To improve the patient safety program at the Naval Hospital at Oak Harbor, the facility instituted a new computerized system of reporting errors, incorporating a nonpunitive approach. The new “Culture of Safety” led to a paradigm shift in assessing an individual's performance, event occurrences, and error reporting. Prior to the patient safety initiative, under the then-existing error reporting system, staff members at the Naval Hospital at Oak Harbor were held personally accountable and subject to discipline for errors they committed. Under the Culture of Safety program, most errors are considered preventable and attributable to systems issues. The new reporting system is used to assess systems failures, not individual performance. Staff may input errors and occurrences directly into the computerized database or submit paper reports. Although anonymous reporting is allowed, staff members are encouraged to identify themselves. Reviewers comment on the errors and occurrences reported to help identify trends and develop baselines for quality improvement activities. Ultimately, the appointed physician advisor for performance improvement summarizes what actions are needed to remediate the problem. The new system provides up-to-the-minute information for review, dissemination, and action, replacing the paper trails and time-consuming meetings that failed to resolve occurrences. Data collected provides feedback to department heads, allowing for monitoring, systems improvement, or environmental changes. Aggregate data are tracked, trended, and fully disseminated.
Introduction
The Naval Hospital at Oak Harbor sought to improve the quality of care provided to our patients by enhancing patient safety. 1, 2 Under our old reporting system, a paper-based Occurrence or Medication Error Report was submitted to the risk manager for action and assignment of reviewers. The paperwork was then sent to each individual reviewer for examination and comment. Only one reviewer at a time could look at and respond to the occurrence report. The system was ineffective, and occurrence reviews took days, weeks, and even months before a final decision could be made on what actions to take. This delay and the lack of timely feedback to hospital staff could lead to reoccurrence of an error.
We needed a new, improved system of reporting occurrences—actual adverse events or near misses that threatened the patients' well-being or put them at higher risk—to replace the old cumbersome and time-consuming reporting system. We needed a system that would focus on preventing errors. 3 The tool, which was locally developed, would serve as a mechanism to monitor, identify, and evaluate all medication errors and other occurrences that happened at our facility. Information gained from each occurrence would serve as an invaluable tool to prevent such events from recurring.
This new system of reporting combined computer technology and a new “Culture of Safety” program within the facility. It called for a nonpunitive approach when dealing with staff and handling errors that occurred. The hospital had to undertake a paradigm shift in the way it assessed individual performance and error reporting. Identified adverse events typically are the result of poorly designed systems that either permit errors or make errors difficult to detect and intercept. The staff was reassured that the new Culture of Safety program was assessing systems failures. A responsive method of catching and reporting errors would allow immediate changes to occur in these systems or the environment of care for our patients and staff. It has been the combination of database technology and the promotion of a culture of safety at our facility that continues to make this program a success. The new reporting system's computerized Occurrence Screen Database allows for up-to-the-minute interactive information for review, dissemination, and action.
System descriptionThe Occurrence Screen Database is based upon the Microsoft® Access database platform. This platform allows the program to easily adapt to any changes or needs of our facility and provides multiple layers of security. The program is password protected and complies with the Health Insurance Portability and Accountability Act (HIPAA) of 1996, 2 requiring protection of private health information. The database also is linked to Microsoft Outlook, allowing for immediate notification of an occurrence that requires review, comment, or prompt action. The database mimics the information needed for the Department of Defense (DoD) Patient Safety Registry (PSR) 3 4 monthly reportsubmitted to the Armed Forces Institution of Pathology (AFIP) 4 5 and the MEDMARXSM medication database 5 input. This aggregate data is useful in comparing our facility's patient safety record to that of other facilities of the same type and size.
System operation
The staff assigned to our facility is encouraged to immediately report any occurrences, errors, or potentially dangerous situations to the patient safety specialist. They are encouraged to identify themselves when submitting an occurrence, but are not required to do so; strict anonymity is kept for those who request it. They also are not required to identify any other staff members involved. Only the patient safety specialist, risk manager, and physician advisor have access to all of the stored information involving the occurrences.
The submitted information is tracked over time and reviewed to see if any trends are occurring that might need more attention. If a trend is discovered, a review of the system or systems in place is conducted to see if any improvements can be made. Staff retraining or reassignment might be necessary, if indicated by the trends. Proactive reviews of high-risk systems are conducted at least annually or when deemed necessary by recurrent events. A well-organized team conducts a Health Care Failure Mode Effects Analysis (HFMEA) on those processes within a system that present the most potential to harm our patients. All stakeholders in the system processes are included within the team. Remedial actions could include changes in policies and procedures, replacing equipment, and retraining staff.If an adverse event does reach a patient, the occurrence or medication error may require a formal review of the process or system. A root-cause analysis (RCA) is performed to systematically identify processes or system problems that result in a variation in performance. If needed, changes in policy or procedure are made to improve patient safety. This form of review is a reactive method to occurrences that have already happened.
The collected data also are provided as feedback to department heads. The department heads are able to determine if personnel need monitoring, systems need improvement, or environmental changes are needed to make the area safer for our patients. The data are fully disseminated throughout the hospital and presented at meetings to the Board of Directors, Executive Committee of Medical Staff, Executive Committee of Nursing Staff, Medical Staff, Pharmacy and Therapeutics, Environment of Care, Executive Steering Committee, Infection Control, and the Patient Safety Committee. Formal reviews of the data collected on the occurrences and medication errors are performed at least monthly by the Patient Safety Committee.
Errors involving providers are reviewed at both Medical Staff Committee meetings and Executive Committee on Medical Staff meetings to determine whether a given occurrence warrants an entry into the Clinical Activity File (CAF) of the provider. The decision to make this type of entry is determined by the provider's peers. The CAF file entry is automatically generated from the database, when deemed appropriate.
Once an occurrence is closed, the risk manager archives the report. The archived report can be used later for tracking and trending data, or recalled for further review.
Like any new system that is implemented, there are barriers at initiation. The Occurrence Screen Database has had numerous barriers to overcome to make it a success. Some of the barriers experienced were as follows:
- “Culture of Safety”: The staff had to be convinced of the nonpunitive approach to error reporting. The hospital directors had to promote the philosophy of prevention instead of punishment when dealing with discovered errors.
- Staff buy-in: The staff had to be active participants and involved in making the program work.
- Technology: As with any new system, the program did have some initial technical difficulties to overcome.
- Training: Training on the new system had to be provided throughout the hospital, requiring many man-hours.
The implementation of the new reporting system and the advent of the Culture of Safety program have seen a dramatic increase in the number of occurrences and errors reported over 2 years. For calendar year 2002, a total of 910 occurrences (786 nonmedication events and 124 medication errors) were reported. The number of reports filed for 2003 increased to 1,661 occurrences (1,434 nonmedication events and 227 medication errors). A much more visible measurement of success is the number of individuals who have self-reported errors. The staff feels confident in knowing that they will not be sanctioned for mistakes that are not malicious in nature. Recently, surveys were taken among the staff on their willingness to report occurrences without fear of retribution. The survey results found that 90 percent of the staff felt confident in their error reporting. A total of 8 percent felt that only a slight chance of adverse actions would be possible. Only 2 percent of our staff did not feel comfortable enough to report any and all occurrences.
An improvement in the timeliness and accuracy of the system was also achieved and facilitated measurement. The previous system could take weeks to months to complete and review an occurrence. Our new system has decreased the average time of occurrence review from months to a maximum of 2 weeks. The usual occurrence can be closed out in as little as 72 hours. The status of any occurrence report can be tracked up-to-the-minute. This automated system of data collection has also made reporting of occurrences to higher authorities 5 easier and more accurate.
AcknowledgmentsThe new system of error reporting at our facility is what has evolved into the Occurrence Screen Database. The program was originally developed by Mr. Terry M. Cook, CDR (ret), RN (risk manager); Captain James E. Kohl, RN, NC (senior nurse executive coordinator); and Mr. Daniel R. Wolniakowski (medical information department head and program designer). Through their unrelenting efforts, the system has been perfected. Lieutenant Scott J. Messmer, RN, NC (performance improvement coordinator) aided in staff compliance when utilizing the new system. It was the collaboration of these individuals and the support of the commanding officer at Naval Hospital, Oak Harbor, that made this project a success.
Captain Susan B. Herrold assumed the command at Naval Hospital, Oak Harbor, in May 2003. Her continued support of the occurrence and medication error reporting system has made it a continued success. Captain Herrold's emphasis on teamwork, patient-centered care, and continuous improvement has furthered the efforts of the system.
1. Kohn LT, Corrigan JM, Donaldson MS, editors. To err is human: building a safer health system. A report of the Committee on Quality of Health Care in America, Institute of Medicine. Washington, DC: National Academy Press; 2000.
2. Institute of Medicine. Patient safety: achieving a new standard for care. Washington, DC: National Academy Press; 2004.
3. O'Leary, D. Patient safety: instilling hospitals with a culture of continuous improvement. Testimony before the Senate Committee on Government Affairs; Jun 11, 2003. Available at: http://www.jcaho.org/news+room/on+capital+hill/061103_testimony.htm .
4. U.S. Department of Defense. DoD Directive 6025.17, Military Health System (MHS) Patient Safety Program (PSP) (MHSPSP). Washington, DC; 2001.
5. U.S. Department of Defense. DoD Directive 5154.24, Armed Forces Institute of Pathology (AFIP). Washington, DC; 2003.
Benefits of computerized database system
Starting in the late Twentieth Century, many companies started using computerized systems. Most of these companies started using these systems to save time and reduce costs. Even though these computerized systems are rather expensive, in the long run they saved companies money. The companies saved money by making or purchasing a computerized system by reducing paper usage and employee overtime. Since employees did not have to spend there time doing paper work, they could do their jobs faster and more efficien
. . .
Many aspects of the computerized system might take away some duties from the human employee. This way, information is kept private or public, depending of the company needs.
Management also benefits from the computerized system.
One computerized system that saved employee’s time is automatic payroll. There is no searching for documents or other files. We see an even larger amount of companies having computerized systems now, in the Twenty-First Century. This can save the company a lot of money, but is very bad for employee morale. Some companies like this idea because it can possibly reduce the number of employees needed in the payroll section of their company.
Although many computerized systems were brought into companies in the late Twentieth century, some companies still do not take advantage of this. Instead of wasting time filling out paper time sheets, the employee could simply “clock” in at the beginning and end of each shift. Soon most, if not all, companies will have computerized systems. Management is able make decisions much faster because the information they needed to make these decisions with is right there and could easily be accessed. This gave the employees more time to do other projects around the office.
Created by: Nikki Joy Castaño
Mgt 7 class 5:15- 6:15
