Your organization may already be equipped with a robust incident reporting solution, but are you tracking and leveraging all the information you can? This e-book will highlight the challenges found in end-user reporting and recommend strategies to improve reporting rates.
Why do low event reporting rates matter?
The US Department of Health and Human Services (HHS) has reported that event reporting rates in hospitals are as low as 14% of all medical errors that occur; in addition, policies and procedures are rarely changed to prevent future recurrence.4
Why are events not reported?
A study published by Khalili et al in the British Medical Journal determined that the primary reasons why front-line staff, such as nurses, did not report all Adverse Drug Reactions (ADRs) was because:
- 21% were not aware of an existing reporting tool
- 24% did not know how to report
- 31% did not know the importance of reporting.3
How do we increase event reporting?
The three factors above will serve as the basis for the recommendations provided in this series. Specifically, we will outline strategies to address the following:
- Promoting the Event Reporting System
- Educating End Users on How to Report
- Ensuring the Importance of Reporting is Understood
Strategy #1: Promoting the event reporting system
Based on the results from Khalili et al, 21% of nurses were not aware that their organization had a reporting tool in place. The good news is that this gap can be addressed through basic marketing and promotion strategies. Some strategies to consider include: holding a naming contest for the reporting tool, throwing a launch party or a lunch and learn session, leveraging social media, and creating promotional items such as posters or clothing to increase the awareness of the tool. All of these methods can be very effective to help build awareness, create excitement and promote the use of your reporting system, especially when it is new.
Even after the system is no longer new, there are multiple strategies that can be leveraged on a regular basis to promote the reporting tool within your organization, such as: print-outs and regular distribution of actual reports for your organization, internal communications of trends for patient safety and knowledge sharing of the reporting tool around the organization. Some specific ideas include:
- POSTER DISPLAYS of relevant and tangible data from the reporting tool to present notable trends within your organization. For example, RL6:Risk can be used to run a trending report on Falls in the ER since RL6:Risk was implemented. Graphs or charts can then be printed and displayed in the ER nursing station for the staff to have a visual reminder of improvements and areas of opportunities in the organization.
- REGULAR DISTRIBUTION OF REPORTS TO STAFF and unit managers showing what’s been reported and changed in the organization as a result of the reports. Sharing this information with your entire organization can help engage staff to contribute to the efforts of improving patient safety. These updates can be in internal newsletters, or other forms of communication.
- ADDING REPORTING METHODS AND PATIENT SAFETY AS A REGULAR AGENDA item for department/unit meetings. Allowing staff to discuss areas of weakness and strategies for improvement can have a big impact on the patient safety of your entire organization.
- THE RISK MANAGER (OR OTHER SYSTEM ADMINISTRATORS) CAN VISIT DIFFERENT UNITS in the hospital to better understand how people are using the software and consider questions such as, “What are the reporting challenges?” and “What makes it easier to report events?”. These can then be addressed by the system administrator.
Strategy #2: Educating end users on how to report
Depending on the baseline of knowledge towards the application, various levels of training, education and support will be required to improve and sustain end-user adoption of the reporting system in your organization. Before determining which approach to use, we recommend running a report on the events that have been submitted by each department (or end-user) to identify what’s being reported and what isn’t. This will help identify areas or groups of staff who require more attention.
Some of the same strategies for promoting the system can also be used to boost education and training for end users. Hosting a lunch-and-learn, for example, can serve two purposes: promoting the system and increasing user adoption and compliance. Within these sessions, it may be helpful to go over different legislative requirements (i.e., what needs to be reported for your organization) while also providing relevant information for each department.
Lunch-and-learn sessions are most beneficial with smaller groups of people. This gives your Risk Management and Patient Safety personnel a chance to connect with staff and perhaps even provide some hands-on learning using relevant examples. You can also leverage educational tools and training aids to boost end-user adoption. Some specific ideas on how to educate end users on the importance of reporting are:
- REVISIT THE TRAINING DOCUMENTS that were provided during the initial implementation. Give them a facelift, refreshing the images and including examples of reports and then redistribute.
- DEVELOP JOB AIDS SUCH AS CHECKLISTS to aid when to report and what to report. These types of aids can be very useful for staff that are not frequent users or who have no time to dedicate to reporting.
- DEVELOP DEPARTMENT-SPECIFIC LISTS of reportable event types and make them available to front-line staff to remind them which events need to be tracked and reported.
- PROVIDE LINKS TO POLICIES AND PROCEDURES to help ensure the correct steps are followed to manage the event. For example, your hospital may have established a patient safety plan that outlines the initial point of contact, file entry, submission, alerts, tasks and closure.
- HELP STAFF REDUCE THE TIME IT TAKES TO REPORT by regularly reviewing forms, pick lists and mandatory fields. Often, the length of these components is fairly large, and can discourage file entry since the task appears more daunting than it really is. This process will also help provide more precise data for your organization.
- ADD TRAINING FOR THE REPORTING TOOL to the HR orientation process. It is very common for healthcare organizations to be faced with high turnover rates. When this occurs, training new staff on the existing reporting tool is often neglected.
- MAKE IT SIMPLE. Speeding up the process of file entry or event reporting can be as simple as inserting an icon to the application on computer desktops. You can also provide a link to the application on the homepage of your organization’s corporate intranet site. These strategies will ensure that access to the application is quick and easy.
Strategy #3: Ensuring the importance of incident reporting is understood
Even though the goal is to improve patient safety at an organizational level, it is important to focus on the learning opportunities for the individual who's reporting. When incident reporting is treated as a learning opportunity, the focus can shift to preventing recurrence, rather than appointing blame.2
Telling staff that reporting is important is not enough; the importance must be demonstrated and reinforced on an ongoing basis. Staff must understand your organization’s patient safety goals and how they can contribute to achieving them.
The more staff report events, the more reporting becomes a part of the safety culture. Children’s Hospital Boston implemented an initiative to increase rates of reporting, and found that with a 35% increase in reported incidents from the medical and surgical units, there was a corresponding decrease in severity levels.1 The study concluded that providing nurses with meaningful data on event reporting and demonstrating the outcomes was critical for developing strategies to prevent future errors.
How do we demonstrate the importance of reporting?
DISPLAY DATA: Showing tangible and relevant data produced directly from the reporting system demonstrates the importance of using a reporting tool. Managers should share department or unit reports with staff regularly to show event volumes and trends over time. Running a report on any notable trend in your organization and printing it along with a reminder to report can have a big impact on user compliance, especially if reporters can see the direct results of their efforts at their department or unit level.
USE ETHOS AND PATHOS: Campaigns that use both ethos and pathos to promote an objective can be very effective at obtaining the desired result. Ethos is a method of persuasive writing in which the author uses fundamental aspects of ethics and morality to convince the audience of a specific concept. Alternatively, pathos uses emotional triggers to do the same.
In terms of patient safety, using ethos may be as simple as displaying the number of preventable fatalities in the medical and surgical units of your facility. This will help convince staff that they can directly contribute to the organization’s efforts to eliminate such harmful mistakes. An approach using pathos may be to include a sympathetic story of a reportable event that could have been prevented by common patient safety practices.
Campaigns that use both ethos and pathos to promote an objective can be very effective at obtaining the desired result.
For example, an elderly patient’s fall from a stretcher and the subsequent lawsuit could have been avoided if the side rails had been checked by each staff person that cared for the patient. These types of campaigns can be very effective at motivating the audience to take action.
COMPETITIONS, REWARDS AND RECOGNITION: Running weekly, monthly or quarterly competitions for end users who have submitted the greatest number of events can be a great way to boost compliance for reporting. In RL Solutions’ software, it is possible to run reports based on the user or department to determine who submitted events within a given period of time. For example, a weekly autoreport can be run and filtered to display Good Catch submissions, then filtered again by department or users to determine the “winners” of the week.
Small rewards can help boost the motivation to compete, for example a small trophy to represent a Good Catch (such as a baseball mitt or a butterfly net) can be passed around to the winning departments each week. Small gift cards or handwritten notes can also be handed out to winning individuals. This initiative is extremely easy to do and can be effective for generating competition, motivation and subsequently, greater compliance with event reporting.
INVOLVE STAFF IN STRATEGIC PLANNING AND DEVELOPMENT: Involving front-line staff in the setting of patient safety goals for their department or unit can improve teamwork and help the organization work towards the common goal of improved patient safety. Tactics that could help create shared ownership for patient safety throughout your organization include:
- SET UP A GENERAL EVENT TYPE OR A FIELD ON EACH EVENT FORM TO CAPTURE SUGGESTIONS FROM END USERS AND FILE MANAGERS. Alerts can also be scheduled to notify system administrators when a suggestion is entered. This will allow end users to contribute their ideas and opinions towards the common goal of improving patient safety in your organization.
- IMPLEMENT A CYCLICAL REVIEW PROCESS. Instead of simply providing managers with the event or issue results from their department, it may be more effective to allow them to finalize the review cycle by providing improvement recommendations for both their hospital department, as well as for the entire organization. Similar to the strategy above, allowing file managers to recommend new strategies for their own team in addition to the entire hospital, will encourage collaboration and help managers feel like their ideas are being heard.
- SHARING RESULTS FOR ANNUAL PATIENT SAFETY INITIATIVES TO SHOW HOW THE ORGANIZATION IS IMPROVING. Beyond simple displays of tangible data to all staff in the hospital, holding collaborative meetings with file managers to share the results of their department and discuss strategies with each other may help improve in those areas.
TRACK POSITIVE EVENT TYPES: Consider changing the tone of event reporting from exclusively tracking negative events to including positive events such as near misses and good catches, as well as always events. Near misses and good catches are more positive event types because the event was caught before it actually reached the patient. Always events are procedures that should occur all the time as part of best practices in a healthcare setting.5 Tracking positive event types will help change the incentives of reporting from reducing harm to developing the optimal patient experience.
Tracking positive event types will help change the incentives of reporting from reducing harm to developing the optimal patient experience.
Since every organization’s culture is different, some of the strategies presented this series may resonate more than others. However, it is clear that organizations that think creatively will get better results. Increasing the understanding of the importance of reporting and making it easy for staff to report an event will not only give you better data to drive your patient safety initiatives, it will also help ensure that patient safety is everyone’s job.
Discover how RL Solutions can help you with quality management reporting — contact us to book a demo today!
About RL Solutions
1 Hession-Laband E, Mantell P. (2011) Lessons learned: use of event reporting by nurses to improve patient safety and quality. Journal of Pediatric Nursing. 26:2, pp. 149-155.
2 Hewitt, T., Chreim, S., & Forster, A. (2014). Sociocultural Factors Influencing Incident Reporting Among Physicians and Nurses: Understanding Frames Underlying Self-and Peer-Reporting Practices. J Patient Saf.
3 Khalili H, Mohebbi N, Hendoiee N, et al. (2012) Improvement of knowledge, attitude and perception of healthcare workers about ADR, a pre- and post-clinical pharmacists’ interventional study. British Medical Journal Open. 2 pp.1-6.
4 Levinson DR (2012) Hospital Incident Reporting Systems Do Not Capture Most Patient Harm. Department of Health and Human Services. OEI-06-09-00091 pp. i-35
5 Picker Institute (2011) Always Events: Creating an Optimal Patient Experience. Pp. 1-17