How to Submit an Event Report

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En provenance du cours de Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

110 notes

Johns Hopkins University

Setting the Stage for Success: An Eye on Safety Culture and Teamwork (Patient Safety II)

110 notes

Cours 2 sur 7 dans Specialization Patient Safety

Safety culture is a facet of organizational culture that captures attitudes, beliefs, perceptions, and values about safety. A culture of safety is essential in high reliability organizations and is a critical mechanism for the delivery of safe and high-quality care. It requires a strong commitment from leadership and staff. In this course, a safe culture is promoted through the use of identifying and reporting patient safety hazards, accountability and transparency, involvement with patients and families, and effective teamwork.

À partir de la leçon

Event Reporting and Second Victims

Patient safety event reports are a critical data source for identifying and mitigating harm in high reliability organizations; yet, many healthcare organizations do not take full advantage of this data. At the conclusion of this module, learners will understand how event reports should be used to design safer care systems and how organizations can provide support to staff involved in medical errors.

How to Submit an Event Report9:25

Journey of an Event Report3:04

Event Reporting and High Reliability3:28

Using Event Reports to Improve Safety and Culture3:09

Reporting Culture4:04

Using Event Reports to Design Safer Systems: Part I2:34

Using Event Reports to Design Safer Systems: Part II5:01

A Sample Event Review Meeting12:34

Introduction to the Learning from Defects Tool12:50

Disclosure of Medical Errors2:49

Second Victims7:30

Peer Support: Making a Difference for Second Victims8:48

Rencontrer les enseignants

Eileen Kasda

[MUSIC]

Welcome, this video is about how to submit a patient safety event report.

Patient safety event reports have historically been paper forms and

in recent years have moved to electronic forms.

Event reports are stories.

They provide a unique chance to share learnings across teams.

We're going to take a second and

look at what it's like to submit an electronic patient safety report.

This is what a sample event reporting form looks like.

Forms have historically been electronic or paper.

In recent years, many forms have moved to electronic submissions,

just like you would submit an order online.

Forms at the top will often say that they are privileged and confidential for

internal peer review only.

This is to ensure sensitivity and

peer-view-privilege protections on this data.

The first question you are asked when submitting an event is,

what was the date of the report?

So we're going to go ahead and practice submitting the event.

Well, today's date is 09/01/2017.

The second question you will get asked often is, who was the event done by?

This is where you should submit your name.

If for some reason you want to submit an event report electronically,

it's okay to just leave the form blank.

In my case, I'll submit my name.

The next box that you will get is called the Event Description.

Here's where you will type in what actually happened in the event.

In this case, we're going to practice submitting an event

involving a patient identification error in registration.

So here we go.

When registering Sandra Johnson.

It's important to include as many details

as you can about the patient, so we'll include

her date of birth as 10/31/1956.

I accidentally selected Sandy Johnson.

With her date of birth 10/13/1966.

Luckily, it's important to also say how you found out about this event.

I found out about this event, because luckily, when I was applying,

The patient's identification band,

which is the arm band that they wear in the hospital,

the patient told me her date of birth was wrong.

At this time I knew that a patient identification error had occurred.

Also when completing the event description it's important to share if

you have any recommendations.

And so in this event, my recommendations

are that it is important to always check two patient identifiers.

For example, name and date of birth would be a source of an identifier.

In this case, I didn't check the patients date of birth,

which is why I didn't catch that I had picked the wrong patient.

In addition, the medical record system,

the electronic system, should have highlighted that

these patients had similar names and dates of birth.

Making it easier for me to pick the right patient.

And that's it,

that's all I have to I have to put in related to the event description.

The next question I'm asked is, who was affected by the event?

Event report systems will often ask you to pick if it's a patient, a visitor,

which could be someone like a subcontractor, an employee, or other.

Employee events are not always captured in a patient safety event reporting system.

Sometimes occupational health databases capture employee events.

So it's important to know which database to put those in.

In this case it was a patient who was affected.

And then the gender of the affected party, in this case is a female.

That would be Sandra Johnson.

And then it's important to put the name of the affected party.

And so we will put Sandra Johnson.

And then to give the patient's medical record number.

So we'll put her identifiers in here.

What's helpful about this then is when someone follows up on the event they

have the information that they need.

So we've already listed Ms. Johnson's identifiers in the event description but

it's important to put these in again.

So we'll put her actual date of birth.

And then where and when the event occurred.

In this case our site was Baycare.

Well, auto-corrected that to daycare.

Let's try this again, Baycare Hospital.

And our location was the Emergency Room Registration.

Some of these location fields may be a drop-down

based off the database that you're using.

And it may pre-populate the locations involved.

Lastly, it asks, what is the date of the event?

The date that you're submitting the event is often the same date that

the event actually occurred.

It's a best practice to put this events in as quickly as possible.

But sometimes with changes of shift or

sometimes the event isn't discovered for one or two days later it's okay,

just submit the date in which the event actually occurred.

It's very helpful for investigation purposes.

So then, this specific event information, when an event is submitted,

you're asked to select an event type that this would apply to.

These event types are an example taken from the AHRQ Common Formats Version 2.0.

And here's a link if you would like to learn more about these.

The Common Formats were developed as a way to standardize data capture fields across

the patient safety industry and so,

many event reporting databases have similar fields.

In this case, we will submit this as an other event since it

doesn't seem to really apply to any of these event types already selected.

The event type is important, though,

because it helps route the event to reviewing managers for followup.

In addition, the last field that you're asked to select, often, is the harm score.

Harm scores range usually from an event that involves no harm to an event that

involves death.

And the reason the harm score is important is because it's often used to route events

to senior leaders and managers for followup.

All events should be reviewed, but it's important to make sure

that those involve severe harm are given attention to more urgently.

So in this case, the event did not involve any harm to the patient, thankfully,

because we were able to catch the event very quickly when putting the ID event on.

And then after that you would just click the Submit button.

And often you will receive an email letting you know that

the event was submitted.

Now that you've seen what an electronic submission looks like,

let's look at two sample event reports.

As we know,

the event specifics really lie in the free text narratives of the event report.

On the left, we have the description where it says, Nurse Smith

was too busy to help me transport the patient, Elle Johnson, to the bathroom.

She slipped on some water, which the cleaning staff never cleaned, and

was bleeding.

The recommendations say Nurse Smith should be less busy.

People should do their jobs.

Is this report really helpful?

I think there's perhaps, better ways to phrase this to be more valuable.

On the right is another description.

The unit was very busy and staff were unavailable to have

a second assist to help a large patient to the restroom.

I attempted to help the patient alone but she slipped on water in the bathroom.

Patient was assisted to the ground but

was noted to have a small contusion on the elbow from hitting the ground.

The physician assessed the patient and ordered an x-ray of her arm,

which was negative for the fracture.

The recommendations say that, scheduling should be revisited.

The unit is understaffed and we need to make sure to report spills and

hazards to cleaning staff so patients are not in danger.

As you can see, the report on the right is far more detailed.

It also more thoughtful recommendations about how to prevent this event from

happening again.

A good narrative includes details about what happened, whether there was harm or

not, what occurred to mitigate harm, and

any ideas regarding how we might prevent this from happening again.

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