7 Components of a Friendly Medical Error-Reporting Environment

"We have a pretty robust safety reporting culture here," says Carrie Tuskey, director of risk management at Detroit-based Henry Ford Health System. But she admits, "It takes a long time to change the mindset in healthcare around error reporting." Here, she shares seven components of HFHS' environment that encourage reporting patient safety events.

Carrie Tuskey1. Leadership support. "One of the most important things is leadership that supports transparency in reporting. If you don't have that, people will be actively discouraged from reporting," Ms. Tuskey says.

2. Appropriate infrastructure. HFHS has an electronic system for collecting and reporting adverse events both internally and externally, to organizations such as the Michigan Health and Hospital Association Patient Safety Organization. The incident reporting system enables leaders to categorize events according to type, like medication errors, pressure ulcers and falls, and assign causal factors, such as communication and distraction. Corrective actions are taken based on individual incidents as well as trended data, leading to improvements in patient safety.

HFHS established a policy describing how the incident reporting system works and why it's important. Being transparent about methods of reporting and using the data for improvement encourages people to report, Ms. Tuskey says.

3. Anonymous reporting. HFHS also allows anonymous reporting, which may allay front-line workers' fears about potential backlash from colleagues and superiors. In addition, reporting adverse events is not punished, but provides an opportunity to improve processes. "Our philosophy for many years has been 'the more we know, the more we can improve,' so we encourage front-line reporting," Ms. Tuskey says.

The anonymous reports, like all safety event reports, are reviewed by not only the unit manager, but also risk management staff, ensuring no reports fall through the cracks.

4. Error disclosure. HFHS adopted the National Quality Forum's safe practice of adverse event disclosure, and has a policy of medical error disclosure to patients and families as well as to a statewide patient safety organization. Establishing policies around reporting and disclosing errors helps build a culture of transparency.  

5. Communication. The health system also has a policy of conducting root cause analyses on sentinel events, the outcomes of which are communicated to leaders and staff. In addition, the HFHS risk staff collaborates with internal communications staff to publish "Great Catches" in weekly system-wide huddles. Following up with front-line workers on what was done with their reports and how improvements were made can encourage reporting, according to Ms. Tuskey.

6. Just culture. In 2004, HFHS expanded its already non-punitive policy for error reporting to a policy based on a "just culture," a model by David Marx, JD. Under this model, managers are provided specific guidance about how to respond to errors based on the nature of the behavior that caused the error:

•    Human error. The error could occur due to a weakness in processes and the system or simply human error. In this case, the person who made the mistake should be consoled and the process should be studied and adjusted to prevent future errors.

•    At-risk behavior. At-risk behavior includes noncompliance with a policy or process, often due to trying to respond to conflicting goals, according to Ms. Tuskey. For example, she says a staff member who needs to draw blood in the early morning may not turn the light on and not label the specimen at the bedside in an effort to improve patient satisfaction. The employee tried to meet the goal of drawing blood and improving patient satisfaction, but did not follow a policy, and as a result put the patient at risk. In this case, the person should be coached on how to meet goals without compromising patient safety.

•    Reckless behavior. An error could occur due to a deliberate decision not to follow practice or policy, causing a large risk to patient safety. In this instance, the person should receive corrective action.

This just culture policy appeals to staff because of its fairness and transparency, and encourages reporting patient safety events, according to Ms. Tuskey.

7. Safety culture. Coinciding with an emphasis on just culture and reporting errors, HFHS continues to develop its patient safety culture. For example, in 2008 it launched a "No Harm Campaign" to reduce adverse events by 50 percent by 2013. By the middle of 2013, HFHS has surpassed the halfway point, reducing harm events by 34 percent. In recognition of its efforts, HFHS received the Malcolm Baldrige National Quality Award and the John M. Eisenberg Patient Safety and Quality Award in 2011.

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