Event Reporting: A Paradigm Shift That Works!

Purpose:
Hospitals rely on incident reporting systems to track and analyze events, improving their usefulness is critical to improve safety. Effective event management identifies potential and real harm. Empowering staff, ensuring actions are taken and feedback delivered promotes maximizing the system.

Significance:
A Culture of Safety is the fundamental responsibility of all staff. This organizational posture promotes reporting and contributes to identifying opportunities to enhance our processes. Identifying, analyzing, and trending information culminating in actions taken can help achieve positive outcomes.

Strategy and Implementation:
In 2009 The State of Rhode Island Department of Health mandated all hospitals secure access to a State and Federally certified Patient Safety Organization. Coalitions sponsored by the Hospital Association of Rhode Island selected GE /Medical Event Reporting System (MERS) as the single state wide reporting structure. The Chief Nurse seized an opportunity to realign event reporting from Risk Management to operations. MERS championed by experienced nurse leader, provides oversight, triage and rapid review of events. The switch to operations has proven invaluable, ensuring actions are followed through and lessons shared. With new organizational polices and emphasis on engaging all staff in reporting our event numbers have grown exponentially. RN Staff quote "'Everyone is encouraged to complete event reports, not only for actual mistakes, but for what is considered a near miss, "'I hear more direct response from events, which has been both encouraging and inspiring'".

Evaluation:
Shifting paradigms lead to a 300% increase in reporting during the inaugural year. First third year two we have seen a 370% increase from baseline. Year one 72% of our Root Cause Analyses (RCA) were voluntary, 18% state mandated. Outcomes: Computer changes, changed policies, new equipment.

Implications for Practice:
Increases in reporting and voluntary RCA's exemplify a willingness to improve and promotes a Culture of Safety. As opportunities are identified shared governance councils will help solve problems and make recommendations for improvements.