There’s little doubt that patient and surgical safety are primary considerations for all healthcare facilities. But in an era when healthcare systems lack uniform standards for reporting adverse events, there remain significant barriers to using this data to make systematic improvements.
Adverse events run the gamut, from HAIs and wrong-site surgery to fires in the OR. There are many barriers to reporting these adverse events, including personal fear of reporting, lack of time and cumbersome or confusing reporting systems. Other issues can be more facility-specific, such as organizational culture, the availability of appropriate resources, and the lack of clear statutory standards for not reporting adverse events.
Why is all of this important? Without an effective reporting system, it’s nearly impossible to understand the causes of adverse events and implement preventive measures. Here are four key benefits of enforcing a consistent and uniform system for reporting adverse events:
Opportunities for Improved Patient & Workplace Safety
Accurate data is king when it comes to increasing patient safety, and gathering this data starts with consistent reporting. It is imperative that surgical facilities work toward this end, especially in light of troubling surgical safety statistics.
The World Health Organization (WHO) finds that one in 10 patients is harmed while receiving hospital care, and that unsafe surgical care procedures cause complications in up to 25% of patients. Further, about 50% of adverse events in hospitalized patients happen in surgical care. The silver lining is that at least half of adverse surgical incidents are preventable.
Researchers, administrators and policymakers depend upon consistent and comprehensive data to provide appropriate health and safety legislation. When adverse events are unreported or under-reported, it delays efforts to improve the safety of patients and workers, and distorts results because the data set is incomplete at best.
Within the healthcare world, non-fatal or non-harmful events are sometimes referred to as near misses, and many of these go unreported. This is problematic because the reporting of these incidents might otherwise reveal trends and information that could help surgical facilities identify hazards and develop interventions to reduce the incidence of future risk.
Consistency of reporting gives risk managers the data they need to change policies and put new practices in place to optimize both patient and worker safety.
Understand System Failures & Contributing Factors
Best practices call for a rigorous reporting of both the type and frequency of adverse events, and that of potential adverse events (near misses). Armed with this information, surgical facilities are better able to identify system failures or breakdowns in safety protocols.
Consider adverse events like burns and fires in the OR, which are frequently caused by electrosurgical units or fiber-optic light cables. An exposed fiber optic light cable tip can burn a surgical drape in a matter of six seconds. Perhaps an attendant notices the burning smell, quickly removes the cable and tamps out the smoldering drape which in this case is not in contact with the patient’s body. If the patient is not harmed, adverse events like these often go unreported.
These kinds of incidents occur with regularity around the world, even as OR fires are largely preventable. Reporting every adverse event or near miss over a consistent period could reveal that incidents of OR fires within a particular surgical facility are far more frequent for particular procedures.
The key takeaway is that identifying individual cases of adverse patient events can lead to a better understanding of where system improvements can be made. What interventions can we put in place to make sure these kinds of events no longer take place within these kinds of surgeries?
The focus naturally shifts away from assigning individual blame to a data-focused strategy for assessing system improvements. Within this environment, individuals at all levels of the healthcare hierarchy will feel safe and empowered to act in the best interest of patient and workplace safety.
Increased Trust & Transparency Within Facilities
The U.S. Bureau of Labor Statistics (BLS) cites several reasons for the ongoing practice of under-reporting, or not reporting adverse events at all. Among them are a general reticence of workers to report adverse events for fear of losing their employment, incentive programs that discourage reporting, and obstacles within OSHA recording regulations that ultimately affect the collection of complete data sets within the healthcare industry.
What can healthcare systems do to address this? The process begins by making an organization-wide commitment to a just culture environment in which all employees are encouraged to report each and every incident. Emphasis should be placed on clear communication, risk mitigation and assessing system failures rather than individual errors. This leads to greater transparency and clearer, more consistent reporting.
Added Protection & Peace of Mind
Reporting adverse events isn’t just about patient safety. It also helps protect healthcare organizations from costly liability claims and financial losses caused by reduced reimbursement for the treatment of preventable conditions acquired while in hospital care.
Essentially, if a healthcare facility is in any way responsible for an adverse event, it should report the event immediately. This early disclosure allows quick action to address patient needs and lays the groundwork for demonstrating prompt handling of the matter in the event that a case does go to court.
Proper adverse event reporting allows healthcare facilities to keep the pace with compliance requirements and safety standards, and provides the peace of mind that only comes with a streamlined system for event reporting.
And, one of the WHO’s 10 facts on patient safety points out that investment in patient safety can lead to significant financial savings for healthcare organizations.
The primary aims of event reporting are to improve patient and workplace safety and to leverage lessons learned to positively change policies and practices. From here, preventive measures and interventions can be implemented to promote system-wide, sustainable change.