Now we're going to talk about Event Reporting and High Reliability.
If you think back to the characteristics of HROs,
these are organizations who operate in unforgiving social and political environments.
They use complex processes to manage complex technologies.
They have potential for surprises and adverse consequences.
They have limited opportunities for learning through experimentation.
They also have widespread accountability with sanctions for substandard performance.
These characteristics are incredibly similar to healthcare.
Where healthcare is different from high reliability organizations though,
is that health care does not have this collective mindfulness
enhancing their ability to identify and correct errors before they escalate.
And unfortunately, we don't have remarkably good and consistent safety outcomes.
Patient Safety Event Reporting Systems are
a fundamental component of an organizational strategy to foster a culture of safety,
and they can be used to communicate safety concerns.
Historically, event reporting systems have been designed in one of two ways.
Mandatory reporting focuses on errors that involve harm or
death and they're really designed to hold folks accountable.
Reporting of mandatory errors may often be required by regulators or accrediting bodies.
Voluntary reporting on the other hand captures a broader set of errors
and really strives to detect system weaknesses before harm occurs.
For both forms of reporting,
mandatory or voluntary reporting,
the goal is really to analyze the information and identify ways to prevent future errors.
Event reporting is a critical data source in
high risk industries but has not been leveraged to its fullest extent in healthcare.
When we think about the mindful organizing infrastructure,
event reporting is an excellent tool to embrace some of these concepts.
When we think about respectful interactions,
event reporting offers an ability for staff to
anonymously or self-identify when reporting.
When we think about heedful interrelating,
event reporting offers a way to monitor for
unintended consequences and downstream impacts of system changes.
When we look at the mindful infrastructure
the first principle preoccupation with failure,
is relevant as event reporting offers a vehicle
to identify early signals of systems issues.
The second principle, our reluctance to simplify applies as
event reporting offers an appropriate way to gather
a diverse perspective on complex system flaws.
Any staff member can submit an event.
When we think about the third principle, sensitivity to operations,
event reporting offers a convenient portal for
frontline staff to voice concerns for safety.
Event reporting systems are usually available on
all computers or other devices for an organization.
When we think about the fourth principle, commitment to resilience,
event reporting offers an opportunity to recognize staff who have gone above and beyond
to ensure patient safety as
well as to support staff who have been involved in a medical error.
The last principle deference to
expertise applies to event reporting as event reporting offers
a space for collaborative problem solving with
identifying diverse perspectives on system issues.
Eileen Kasda
