Baystate Health (BH) has created a culture that encourages open, non-punitive error reporting, with professional accountability, as part of its desire to create a safer environment for patients, visitors and employees. The cornerstone of the safety culture is identifying adverse events. Knowing what actions and decisions led to a safety event is important in order to understand and correct systemic errors and to plan improvements. Besides the Safety Reporting System (SRS) in which employees report all events and near-misses, global trigger tools, serious reportable events (SRE), patient safety indicators (PSI), hospital-acquired conditions (HAC), clinical risk management (claims) including review, and mandatory reporting of “never events” are also reliable sources of information. “Never events” and hospital-acquired conditions are lists of reasonably preventable events so serious that they should never happen (e.g., surgery on the wrong body part, mismatched blood transfusion). These events occur when there is a failure in the delivery of healthcare services, too often resulting in unintended injury, illness or death. The lists have been endorsed by the Centers for Medicare and Medicaid Services, The Joint Commission and the National Quality Forum. To see a complete list of never events, please click here: Never Events
The SRS provides BH with a timely, standardized system for collecting and processing information on all safety events. With SRS, reported events are classified by event type and cause, using a standardized description and classification scheme and can be compared with other like facilities using the SRS. The current reporting process can be done by completing a paper-based form or by using the web-based data entry application, and provides automated notification of each report to ensure timely attention, evaluation, and if need be, intervention.
Safety events are analyzed, categorized, and used to develop prevention interventions and to drive improvement. Unit-specific information is shared with all staff to help heighten awareness and encourage unit-based problem solving. By keeping all reported data anonymous, BH has focused on understanding the “what” and “how,” and not the “who” behind events.
Trend data is provided to each unit and shared with clinical leadership, the service-specific performance improvement team, the Nursing Clinical Practice Committee, the Performance Improvement Council, and the Board of Trustees.
BH was one of the first health systems in the nation to begin “Senior Leader Safety Walk Rounds.” Senior management makes regular rounds, discussing patient safety issues and SRS reports with direct care staff on all hospital units. This allows senior leaders to see first-hand the work environment and potential risks that are encountered every day, to dedicate resources in a timely manner, and to hear directly from front line staff their thoughts on what and when the next event will occur.
BH was also one of the early adopters of “learning” from near-miss and actual events. Each event is reviewed and considered an opportunity to learn about our processes and why they failed. That information is used to redesign the flawed process and to prevent it from occurring in the future. Additionally, a standardized process and accompanying tool, “Medical Error Algorithm,” have been developed and implemented to ensure all events are consistently investigated and managed in an objective way.
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