Patient Safety Tool Helps ID Hospital Errors

Cheryl Clark, for HealthLeaders Media , January 10, 2013

At other organizations, staff may not report that incident because it was caught, she says.

Holbrook of the University of Kentucky echoed that view.

Before Common Formats, "we didn't have a very good system for reporting. It was hit or miss," and frontline staff didn't have a good understanding of what they should report.

"It might never escalate to my level, and we would never have taken action. It might have just been back chatter in the hallway, like, 'We nearly operated on the wrong patient. Well, you know, if you don't tell, I won't tell. And it would have been swept under the rug."

Of course, moving frontline providers to this reporting system has its obstacles, one of which is cost and hours spent in reviewing them.

"It requires resources to look at this data, to put it in these buckets and analyze it," Tickner says. "And that's where we find the greatest challenge. It takes time and people. But if you prevent events from happening to patients, that's the tradeoff."

She added that despite the county's encouragement for providers to report as much as possible, "that's not to say that the message has gotten out. I'm not claiming we're saturated with people who are willing to report. It takes time and judgment for people to not think that an event was not important because it didn't reach the patient, but that it still can be a significant event."

Holbrook says she now spends "hours logging and analyzing and classifying" 200 or more reports each week, and doing root-cause analyses involving serious issues, including those that don't harm a patient. But for her, the effort has been worth it. "We're not talking about just lost life, limb, and function, and the financial losses and the cost of litigation that preventing these events avoids; we're also talking about the secondary losses and impact on healthcare providers who may suffer grief, lose a license, suffer posttraumatic stress disorder, or not be able to work with certain patients anymore," she says. "If you don't use Common Formats and you don't actively support, advocate, or encourage and reward incident reporting, you're going to have mistakes blow up in your face," Holbrook says.

Reprint HLR1212-9

This article appears in the December 2012 issue of HealthLeaders magazine.

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