Thursday, April 28, 2005

Development of an Integrated System for Reporting, Analyzing and Learning from Adverse Incidents involving Patients, Staff and Others

Leroy Mell and Shirley Knelly.

An integrated system for the reporting, analysis and learning from adverse incidents has been developed to improve patient safety. The expected outcome of this process is to identify all patient related adverse incidents, explore the root causes and develop and implement plans to prevent occurrence.

Key objectives are:
1. Foster a no-blame culture that identifies opportunities for learning and change across the organization.
2. Utilize outcomes from investigation and analysis of individual, adverse incidents to enable change and improvements to reduce errors and improve patient safety.

A patient safety hotline has been established for anyone to report any incident related to patient safety. Calls are confidential and logged into a central database. The incident reporting system includes the following:
1. All incidents, clinical and non-clinical, for patients, staff, visitors are reported in real time.
2. Alerts Risk Management of incidents which require reporting to an external body.
3. Assigns a code of severity.
4. Provides for reporting of near-misses anonymously
5. Categorizes incidents according to predefined areas of concern enabling analysis of trends and practices. Tools may include FEMA, PDCA, and RCA.
6. Generates specific reports to identified trends.

Using data generated from the hotline database, laboratory blood bank and overall labeling error rates were quantified and investigated using FEMA. Specific procedures to include double identifier procedures, specific and targeted educational programs and a phlebotomy team reduced laboratory labeling error rates to < 0.07%.

The 4-PTS-hotline database provides a real-time mechanism for identifying, investigating, tracking and trending of adverse incidents and which can assist in the overall reduction of errors both in the laboratory and health system.

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See more of The 2005 Institute for Quality in Laboratory Medicine Conference